87-2506 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r i 1601 E. HAZE T ON AVE., STOCKTON, CA ND k.,J LL, ! Telephone (209) 466-6781 ®^ PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ^� (Complete in TripGcatela�+ �y.:� 'INN' Application is hereby made to a San sewage or No. 1862 for well/pump and the Rules and Regulations of the Splications is Joaquin Local Health District for a permit to construct and/or install the work herein described. This ap made in compliance with San Joaquin County Ordinance No.549 for an Joaquin Local Health District. Job Address l—s—D i City-i74 . �,j�f/� Lot Size PM Owner's Name Address j ..cc�� Q-[t•C�L�� f�_.- Phone Q �' %Rontractorcl� Address r / Q License No. Phone TYPE OF WELL-!PUMP: -,-NEW.,WEI L ❑AJEUNI11WELL_REPI=ACill❑�..�r..DESTRUCTION, ❑ _ PUMP,INS TION ❑ SYSTEM REPAIR ❑ '� OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LfNE5 DISPOSA y k PROP. LINE ; FOUNDATION LINE Will OTHER WELL ,PITS/SUMPS _ "�5lMPf INTENDED USE TYPE OF WELL PROBL - C _ TION SPE_CIFICAT_IONS _ O © Industrial r ❑ Open Bottom Manteca) Dia. of Well Excavatio 17) Domestic/Private ❑ Gra ack L1 Tracy Type of CasingDia. of Well Casing Fl Public _ Other Cl Delta Depth of Grout Seal Specifications I I Irrigation Irri Ty Grout _ g" �--Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H p - State Work Done + Well Destruction ❑ Well DiahiLt. meter Sealing Material (top 501 ,P DeptFi Filler Material {Below 50,1k TYPE OF SEPTIC,WORK 'INSTALLATION I 1 REPAIR/ADDITION7 1"`DESTRUCTION (No septic system permitted if public sewer is w Installation will serve: Residence Com'merciai_ Other available within 200 feet.) Number of living units: J— ,Number of bedrooms Character of-soil to a depth of 3 feet: ..t7Z,zy SEPTIC TANKS Water table depth ❑ Type/Mfg Capacity No. Compartments + PKG. TREATMENT PLT. ❑ r� MethodTof Disposal �. Distance to nearest: ell od Founlation P�rnrty.Line LEACHING LINE ❑ No. & Length of lines _ +.F. _ . C' _ Total le gth�/s e 5 FILTER BED' ❑ Distance to nearest: Well .. Foundation"r ��w-k" <Pro.Irty1 e ■ N�'t+f SEEPAGE P! I I Depth r Siza L xl I Number s � aGr+•y SUMPS L7 Distance to nearest:-_ Well � Foundatiori>' � Property Line DISPOSAL PO pS ❑ � hereby certify tthat I have prepared this application and that the work will be done in accordance with San Joaquin couniy,ordinances, state laws, and rules and.regulalions of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of th work for which this pent 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 orsu&-contracting signature certifies the following: "I certify that,in the performance of the work for which this permit is issued, I shall employ tion laws of,-California." E p y persons subjecl,Wworkman's compensa- The applicant-must call for all requited• spection Complete drawing on reverse side. S'9 dx„ .1 41 '�01 Title. Date:t r FOR SPAR NT USE ONLYfyfj y �I =�4� h Application Accepted by E 1 E Date LA 9 Area y Pit or Grout Inspection bate Final Inspection by � Date Additional Comments: ❑ Stk 466-8781 ❑ Lodi�369f3621•-�+..❑ Manteca-823- 1 LI Tracy-635-6385 Applicant - Return all Copies.to: Environmental Health Permit/Services 1601'E,-Hazelton Ave., P.O. Box 2009, Stk., CA 9r 01 O t FEE AMOUNT DUE AMOUNT REMITTED CK $ INFO CASH RECEIVED BY DATE PERMET-NO. ♦. 73-241REV.iin5f 1 EH 14-28