88-2173 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 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 Gpunty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 6 Job Address 1,00y. //Lbl►/VlOii/ �!� City Lot Size C AC.409' PM 9� I Owner's Name 704,0- 1deAle4 s Address oK N Zn. 7l 4 AA PhoneZZACY i Contractor A'ddress ;2 License No,%?,�,� Dy Phone i I TYPE OF WELLIPUMP: NEW WELLK WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 'r DISTANCETONEAREST: SEPTIC TANK /Oa z SEWER LINES DISPOSAL FLD.,e ! PROP. LINE ieA FOUNDATION 1S' AGRICULTURE WELL J�S'b OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Oen Bottom ❑ Manteca Dia. of Well Excavation Open oQ f—It' Dia, of Well Casing i Domestic/Private ravel Pack ❑ Tracy Type of Casing p/l[_ / Specifications /�Q I'] Public f] Other j n Delta Depth of Grout Seal �' Type of Grout-�c I I Irrigation Approxttt Depth i I Eastern Surface Seal Installed by .SCfl e. pen ',F re, -- F _ Repair Work Done ❑ Type of Pump 5714 4 H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1- Depth ! Filler Material 1Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I..I DESTR`1CTfON 1'•1 (No septic system permitted if public sewer is W t available within 200 feet.) Installation will serve: Residence! Commercial_ Other• Number of living units: Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑, Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑, No: & Length of lines Total length/size. FILTER BED ❑ Distance to nearest: Well Foundation Property Line / f a SEEPAGE PITS l I Depth Size Number SUMPS ❑ 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. 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 L employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature [�e— certifies the following: "(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." _ 4 The applicant must call for all required'inspectio s. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Date �J[� , / Pit or Grout Inspection by Dale �/ rra 7 Final Inspection by -,} Date Additional Comments: _Ih��l�rl � i (L (5L I, �[r,_„ 1�"�I +� ❑ Stk 466-6781 ❑ Lodi 369-3621 - .Meta 823-7104 ❑ Tracy 835-&-485 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE INFO AMOUNT DUE AMOUNT REMITTED y`IC t ]� RECEIVED 9!Y DATE [, (PERMIT'NO. r.EH 13-24 IREV,I/H s7 {,S. �'V v�-/ r 7 ` Y V .r f/. EH 14-28 v