88-922 - Laserfiche WebLink

Home Browse Search

r� 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) �2,3Cf—f&0 0 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. Jp-per,(/: S F_Q u-0 t A ! �1� Job Address Jl Ph _-_ City t- Lot Size PM Owner's Name L Address SXo _s7 TA 7—e-a� if/U"t Phone[QO34` T Z0 3� QK / �Contractor c �� . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERAVcN,,,,,,,V1e11 DISTANCE TO NEAREST: SEPTIC TANK:i A114 SEWER LINES d 'ij DISPOSAL FLO.A1154 _ POOP. LINE FOUNDATION S^30' AGRICULTURE LL�mr� OTHER WELL L PITS/SUMPS /U� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -y i 11 Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private XGravel Pack -Ii WTracy Type of Casing pye-1 Specifications Q M Public Ll Other C1 Delta Depth of Grout Seal y ,Type of Grout del"L' _4 ? i I Irrigation /r.-Approx. Depth I I Eastern Surfac Seal Installed by Sr PR[r^ Repair Work Done Ll Type of Pump - -- H.P. /U State Work Done. /U Well Destruction El Well Diameter Zig sealing Material (top 50'I �� P nr 3�a �{ !arc ,r Depth Filler Material IBelow 501 c4,as f i`1'Br trpG k belnc,_, be rrr'f-- t-x TYPE OF SEPTIC WORK: NEW INSTALLATION tREPAIR/ADDITION f I DESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.) 17) Installation will serve: Residence_ Commercial_ Other I Number of living units: Number.of bedrooms [` Character of soil to a depth of 3 feet: ! Water table depth ® ) SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments S ' PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Property Line - LEACHING LINE ❑ No. & Length of lines Total length/size l l FILTER BED ❑ Distance to nearest: Well Foundation Property Line i -k SEEPAGE PITS I I Depth i Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line ;# DISPOSAL PONDS ❑ .„ E 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. , r 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' s ch manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the follow' g: 'I certify t t the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa tion laws of Calif rn" The applicant st IV f all inspections. Complete drawing on reverse-sfAe. Signed Title: Date: A—al FORDEPARTMENTUSE ONLY u i Application Accepted by .,a1 ,t ' f�o� �cei?l�� - Date `�f��&fr Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 44 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ka I1ASl A;1.11 q V.J-.tFEE INFO AMOUNT Dt AMOUNT REMITTED K H RECEIVED BY DATE PERMIT N0. r k' + EH 13-24 IREV.r i e 5l EH 1428