88-3136 - Laserfiche WebLink

Home Browse Search

�p� �o a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. 'HAZEL T ON AVE., STOCKTON, CA !! Telephone (209) 466-6781 PERMIT EXPIRES 1,-YEAR FROM DATE ISSUED (Complete in Triplicate) -2-0? Z `7 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_of No, 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. !_700 •Ov=+�✓ . s _*�'\ prr� Job Address0QQ, 1�t tel!LG City Lot Sine r PM 11r ii ' Name � PhgneW= Ownerp LNdr N G;Y1,ZRlCt•t5F_ (OM1 Mpm Contractor L �� }4 �5;=. Address 1:11601: deRlw a I� License No.r 'ala Phone 7^7�Z TYPE OF WELL/PUMP: NEW WELL 1k WELL REPLACEMENT ❑ DESTRUCTION Ll PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK =SEWER LINES DISPOSAL FLD. PROP. LINE r I1 FOUNDATION � AGRICULTURE WELL fn`_- OTHER VIIELL '— + :PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONDTRUCTION SPECIFICATION F a ' Industrial Open Bottom ❑ Manteca Dia. of Well Excayation: - Dia. of Well Casing^ / ❑ Domestic/Private ❑ Gravel.Pack 1j�Tracy Type of Casing � �� t+I?� Specifications �(.�++�C-�f, f'l Public Cl Other ❑ Delta Depth of Grout Seal `t!)Q r Type of rout;l� � �� Ql 1 I 1 Irrigation .Approx. Depth I Eastern Surface Seal Installed by;��e-'Lt '� � - Repair Work Done ❑ Type of Pump SAN ' H.P. �? State Work Done Well Destruction ❑ Well Diameter ; Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION-.I I DESTRUCTION ! I (No septic system permitted if public sewer is I/3 available within 200 feet.) Installation-will serve: Residence •. Commercial_ Other 'w _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f _• Water table depth SEPTIC TANK ❑ Type/Mfg € Capacity -.,;-_No. Compartments r PKG. TREATMENT PLT. ❑ 11 Method of Disposal Distance to nearest: Well Foundation PropertyLine " �I LEACHING LINE ❑ No. & Length of lines -fi Total length/size r FILTER BED ❑ Distance to nearest: .$*W11 - Foundation Property Line SEEPAGE PITS f I Depth -Size ti- ' i Number A SUMPS ❑ Distance to nearest: Well, Foundation Property Line DISPOSAL PONDS El -ii . 3^,. `' { -4 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 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." i h The applicant t call for all iequire inspections. Complete drawing on reverse side. rp Signed X Tiile: e'�c�]n�Mo'A C.1 OR— Date: vr FO,01M"T USE ONLY r a• Application Accepted by '' Date � � Area (55 — Pit r Grout spection by Date AJ— 4 ' Final Insonction by Date i� Additional Comments: i s Gr/��' cJcaJ,4jjt� Cu - �•mom /l.�/�JI3 e El Stk 466-6781 ❑tod1 369-3621 ElManteca r,,;s d Li`Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.,Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH K 4 RECEIVED BY DATE PERMIT-NO, +.EH 13-24(REV.1 i y 5) [.,� ( E6 EH 14-20 xf i7