88-339 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 6 SAN JOAQUIN LOCAL HEALTH DISTRICT e 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone 1209) 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 witli San Joaquin_County Ordinance No.549 fo sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ^ t W6Job Address p Ivy .0t Size PM Owner's Name Address! t� i 1 �Phone Contract ess License No. Phon6z— TYPE OF WELL/PUMP: .. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingFyL Specifications' FI Public 17 Other I1 Delta Depth of Grout Seal pr, Type 4 Grout II , aatt,00nn I Approx. Depth I I Eastern Surface Seal Installed by pdit111�Grk L Type of Pump H.P. State Work Done_ �J IL Well Destruction ❑ Well Diameter Sealing Material (top 501 ` Depth _ Filler Material (Below 501 1^ •-TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I l DESTRUCTION I I INo septic system permitted if public sewer is 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. ❑ 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 SEEPAGE PITS I I [Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 -"i 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 ' ia . The applic t t call f a re i ins cti to drawing on reverse-side. Signed X f Title. k�orapate: B 6 1988 FOR DEPARTMENT USE ONLY Applica Ion Accepted by . Date 19— Area .e Pit oT Grout Inspection by Date Final Inspection by ` Date Additional Comments: G' I r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to::: Environmental Health Permit/Services)�01 E. Hazelton Ave. .0. Box 2009, Stk., CA 95201 IFEE NFO y//A�MOU/N/T�)DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH 13-24(REV,7/n sl T �U �(� _YX EH 14-26 0 I 4 _.