87-3609 - Laserfiche WebLink

Home Browse Search

s. APPLICATION FOR,PERMIT .a 6 7 ' 1 S'7 SAN JOA LOCAL HEALTH DISTRICT I I S S " -.. Jupt� 1601 E. HAZEL T ON AVE., STOCKTON, CA �. �� $ �/$ zr✓1 Telephone (209) 466 6781 PERMIT EXPIRES VYEAR FROM DATE ISSUED (Complete in Triplicate) 1 L -0 � CID movRrhR�j.r 1 r�--i k �N ,e is�� . 10) Application is hereby made to the County ordinance No.549 far sewage alth District for a permit 1No. 1862 for wellipump and the Rules and(Regulations of the San'Joaquin made in compliance with San Joaquin { Local HIS11yy OOistr Q ,}Q" C3 k8, PM City ';! Lot Size Job AddressT 4 � y Phone Address '` Owner's Name a r��'1 5ife t.. Contractor OL-t VAS P_t� address ,c icense No. 3 Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP; SYSTEM REPAIR ❑ OTHER '��*" j©"�`� ��g F PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLA. PROP. LINE c DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �+ ❑ Industrial ❑ Open Bottom ' Manteca Dia. of Well Excavation rr Dia. of Well Casing Type of Casing VF Specifications LJ Domestic/Private V(Gravel Pack ❑ Tracy ria 1 Type of Grout t4ja�. r^ C'1 Public 11 Other Y Cl Delta k Depth of Grout Seal I Irrigation Approx. Depth I I Eastern Surface Seal Installed by H p — Repair Work Done ❑ Type of Pump State Work Done _ e I A— 1 Well Destruction ❑ Well Diameter— Sealing Material (top 50'1 -� f Depth Va"- k?o filler Material IBelow 501 1 F.tA'nn"�f� TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION l 1 DESTRUCTION I i aNailabpe1withinstem 8200 fe�tifed if public sewer is Installation willserve: Residence_ Commercial/ Other ` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth _ Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg'r,. a , Method of Disposal PKG. TREATMENT PLT. ❑ r Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number J SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. I 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 signature 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- tion laws of California." The applica ust call for all required inspec Complete drawing on reverse side. Signed X Title: Date: d FOR DEPARTMENT USE ONLY Date Area r ApplicatioX�, by 1 s it or Groon b�U/� Date Final Inspection by l ^ ` 37 Date A ��- - c �c dditi ammenI ❑ Stk 466-6781 ❑ Lodi 369 621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r °Cry Applicant-. Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave"., Ppp.O. f�A � /�01 �*y CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO + EH 13.24IREV. N5Y EH 14-26