COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

,JK Pilo i keel' rA Wo e IL f Ic : Y'kr f-- tAd VP- APPLICATION FOR PERMIT . la Vitk ' 4-1/1:4. i45ce r-*" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA P AV tit titf 43 U.L, Telephone (209) 466-6781 RSCSINIS° (Complete in Triplicate) SAN JOAQUIN LOCAL HEALTH 114 f EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH DIVISION SPECIAL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the mai l. 41q, 1 , tistiimcf s a n Joaquin aja3lication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and theillOb lkill 4.r.4 PERMIT Local Health District. PE' Job Address 1 Lak 1- Pt-rmq 'CA' 4 ?,3),.caCkwAtir\idcAl City -4"0(..--V-4731 Lot Size H&1 cit(e6 PM 0 r ...1 Owner's Name elhafkr NA161 C9CCLIL1 Address 41 io 0 r-A-tov-yi P\A,1 efjeu- e,-11- Phone 1 . ..,.., I Contractor 6i I-Tory-toy\ veitti 4. .i .. beo' a. 1-0 !..,.• it - cense No.ii "1 25 (0 Phone tqiitri ii -C) lAddress TYPE OF WELL/PUMP: NE ELL 32C WELL ' PLACEMENT 0 DESTRUCTION 0 REPAIR 0 OTHER 0 DISPOSAL FLD. PROP. LINE PUMP INSTALLATION 0 SYSTEM DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well A Domestic/Private Gravel Pack 0 Tracy Type of Ii Public Ii Other 17 Delta Depth of I I Irrigation ak Approx. Depth I I Eastern Surface Excavation " Dia. of Well Casing Casing Ci% . Lit P VC- Specifications Grout Seal Type of Grout e-le"\"64-41iiki4C1, Seal Installed by A-11--T•ev-cr.4, i yi vv- i ( t i nA ,....) Repair Work Done 0 Type of Pump ki /16c H.P. State Work Done . Well Destruction 0 Well Diameter fa." Sealing Material (top 50') Depth Ne L2 '..., Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units • Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Distance to nearest: Well Foundation Method of Disposal Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 , 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 Diltrict. 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 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, SAIM inbawrfqntelesAt tfatfAtrrpit'Efistrereir tion laws of California." ENVIRONMENTAL HEALTH DIVISION The applicant st call for all re uired inspe ions. Complete drawing on reverse side. P'"......L. SPECIAL ?litithliT_ Signed X Title: nt ) Date: ` FOR DEPARTMENT USE ONLY Date /1- 2 3 -88 Area Date V- 11- C'Final Inspection by /6 Date /A 24- Cri# Additional Comments: Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-63R-S Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -+ Application Accepted by Pit or Grout Inspection by + EH 13-24 (REV. I/M 5 EH 14-24 FEE INFO AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE PERMIT . NO. 70 -66 76). (16 //,76146 Z.4, /(--;hri 71-SI "V,