86-1683 - Laserfiche WebLink

Home Browse Search

ii APPLICATION FOR PERMIT `! SAN JOAQUIN-LOCAL HEALTH DISTRICT HAZE;.i ON AVE., STOCKTON, CA 1601 E.. 6781 r Telephone {2091 - DATE ISSUED i w PERMIT EXPIRES 1 YEAR FROM - ii This application is andlor'install(Complete in Triplicate} and the Rules and Regulations of the San Joaquin Joaquin Local Health District for a permit to construct 162 or weIII pump and the work herein descri [� for sewage or No Application is hereby made n the San Joan Ordinance No.549 r I App fiance with San Joaquin County made in compliance Local Health District. City Lot Size 1 t ' Job Address M � � . � / k Address ; / e - ��;� Phone ' Owner's Name, i f License NO. essDESTRUCTION !� WELL REPLACEMENT ❑ ER ❑ Contractor NEW WELL ❑ it SYSTEM REPAIR ❑ FLD.� PROP. LINE TYPE OF WELLIPUM ' PUMP INSTALLATION ❑ a .,SEWER LINES � DIS WELL PiTS1SUMPS AGRICULTURE WELL " DISTANCE TO NEAREST: SEPTIC TANK �.� FOUNDATIONC TYPE OF UCTION SPECIFICATIONS pia- of Well Casing AREA ` I WELL PROBLEM .. Die! of Well Excavation Specifications INTENDED USE ❑ rylantec Type of Casing Type of Grout [3 Industrial ❑ Open Bottom acy .I ❑ Gravel Pack Depth of Grout Seal ❑ Domestic/Private ❑ Delta y ❑ Other Surface Seal Installed by ED Public IDepth ❑ Eastern State Work Done ' I ❑ irrigation H.P. Repair Work Done Type of Pump �— Sealing Material (top 501 F We11 Destro ❑ Well Diameter Filler Material (Below 50') em ermined if public sewer is ;Depth DESTRUCTION ❑ aNailablerwithin 200 feet.) 's+ INSTALLATION REPAlR1ADDlT10N ❑ TYPE OF SEPTIC VYORK: NEW ,/ 1 Commercial, Other Installation will serve: A Water table depth ^*� Number of bedrooms .f Number of living units: J. M •. ; No. Compartments S t C+� �. ,, �_ Capacity _ Character of soil to a depth of 3 feet: r .`- ,M Method of Di osal ❑ Type/Mfg �� SEPTIC TANKS Property Line l PKC. TREATMENT PLT. ❑ Well�/iv— Foundation i ' Distance to nearest: y t _ T tat length/size ❑ x No. &Length of lines' x° 17 Property Line j LINE Well TV— LEACHING Foundation 5 FILTER BED ❑ Distance to nearest: ` Number i Size. Property Line SEEPAGE PiTS ❑ Depth { Foundation- UMPDistance to nearest: Well f L PONDS ❑ . DISPOSAL application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and I hereby certify that I have prepared this app g I certify that in the performance of the work for which this permit is issued,l shaft not rules and regulations of the San Joaquin Local Health District. i snail employ persons subject to workman's compensa- Home owner or licensed agent's signature certifies the following= „ r which this permit is issued, manner as to became subject to workm f's compensation laws of California." Contractor's hiring or sub-cantractrng signature r employ any person in such rformance of the work I certify that in the pe certifies the following:," ' side. tion laws of California." The applicant m c r all requir ns ctions. Complet` drawing on r } Date: Title: , f Signed FOR DEPARTMENT USE ONLY Area f Date + i i, Date s Application Accepted by / Final inspection by Date( t Pit or Grout Inspection by .1 IR i 7104 ❑ Tracy 8354385 Additional Comments: odi 3W-3621 ❑ Manteca 823tk., CA 95201 ❑ Stk 466.6781 ' Applicant-.Return all copies to: Environmental Health11 PsrmitlServices 1601 E. Hazelton Ave., P.O.POBox CK RECEIVED BY DATE PERMIT NO. l FEE AMOUNT DUE AMOUNT REMITTED CASH Z INFO , f or �F�— 'rt +EH 1324 IREV:fls 57 •.�p p a — -- - - EH 14.26 -7t--