88-873 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA if Telephone (209),466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i T (Complete in Triplicate) I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �-!�. City Lot Size PM Job Address dt .. l� AUL Address _� ' / fC'`.v-`„' �a Phone Owner's Name F_04466C Address License No. Phone 'Contractor_ _ _ - .TYPE OF WELLIPUMP: ,wNEW WELL ❑ � WELL REPLACEMENT ❑ � DESTRUCTION ❑ PUMP INSTALU•�TION ❑ SYSTEM REPAIR ❑ OTHER 171t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.' PROP. LINE FOUNDATION AGRICULTURE WELL.- " OTHER WELL R1TTSISUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f Well Casing o 17 Industrial ❑ Open f3ottom- LI Manteca Dia. of Well-Excavation pia. . Type'• ❑ Domestic/Private C1 Gravel Pack j ❑ TTracy _ YR of Casing Specifications rr Type of Grout f1 Public`sn Other 3 Cl Delta ' Oepth.of Grout Seal A roil. Depth I 1 Eastern 4 f Surface Si3a1-installed by I 1 Irrigation k t x-:: - pp s a. . Repair Work Done ❑ Type of frump-_ 'H-P. ` State Work Done_ 0� t. } y Well Destruction .4❑1 Well,Diameterx- Sealing Material Itdp Depth.1 f ` '� Filler Material [Below 501' . i TYPE OF SEPTIC-WORK: NIEW INSTFrLLQT•ION REP,AIRIADDITION l I. DESTRUCTION l 1 Wo septic system permitted if public sewer is yi i feet. I available 1n 00 I a le with Installation will serve: Residence/�` ommer�iaP = ther Number of living units: J "Number of fiedrooms + �* 1 S1 D Character of soil to a,depth of 3 feet: Water table depth �s, € SEP-T•IC,TANK � - � C7 TypelNlfg Capacity ts No. Compartmen ! '* "' Method of Disposal PKG" TREATMENT,PLT. L34/7 Distance i nearest: _ " 'Well Foundation � b a _ Property Line�L—fir x=Y -- Totablengihlsize • _ lir LEACHING LINE 111M, "� No�& Length of lines- A `� �.,7— y� "'7'-i FILTER BED 7 C] Distance to nearest: Welly Foundation - Property Liner SEEPAGE PITS I } D pj�' Size Number SUMPS Distance;to nearest: Well © Foundation �� Property Line f € 4, DISPOSAL PONDS © �.- II I hereby certify that I have prepared`this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and.. rules and regulations of the San Joaquin Local Health District. ` Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not: .,. . employ any person in such manner as to become subject to workman's compensation laws of California."Contractor s hiring or sub-contracting;srgnature,,.. certifies the following: "'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa 7 lion laws of California." The applicant must call f . all wired inspections. Complete drawing on reverse side. /g- Signed X z Title: Date:00, - - 5 FORARTMENT USE ONLY 13' Application Accepted by Date Area Pit or Grout Inspection by Date Fina! Inspection by_ Date Additional Comments: + I Z ❑ Stk 466-6781 0 Lodi 369-3621 E] Manteca 623-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 --FEE - CK RECEIVED 6Y PATE PERMIT NO.,,! INFO /CMOUNT.DUE .. - AI OuNT REMITTED� CASH._,. - ._...�q�,,, !L - �� ... _ r EH 13.24 ISM 1/951 IEH 14-26 �� 0