84-388 - Laserfiche WebLink

Home Browse Search

• w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE:T ON AVE', STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - I (Complete in Triplicate) { I 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 County Ordinance No.549 for sewage or No..1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. _ I , t 3 'Alf1L 411 AMC Job Address 3 City Lot Size 17.45 e4ol-zdPM � Owner's Name ,EMI L H I EB Address ' 1 1 13 /✓. �' 1-4 N4' Phone `36 rT- 9-515/ Contractor's !Name License No. W d LIP, Phone16-'1654� TYPE OF WELL/PUMP: I NEWyWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y- t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE,TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION.L�'*AGRICUL•TURE WE'LC"L "'OTHER V ELL'-�N -PITS/SUMP_S_ 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 Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 - ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by `t`^ " Repair Work,Done - ❑ -Type-of HStateWork'Done^-1— k Well,De �ctionr--❑�-Well Diameter�j ,� Sealing Material stop 50'1 Depth -s' -` -Filler Mat6fibl-(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ -DESTRUCTION ❑ (No septic-system permitted if public sewer is +� t available within 200 feet.) Installation will serve: Residence-1- Commercial=. Offer ! #° Number of living units: Number,of bedrooms ? Character of sol! oia'depth of 3 feet /QPIz °CL. y--c L�p%17 # I Water table depth ,`� �. SEPTIC TANK_:",^ `Type/Mfg--E-RN/E_S ' SEP77C 'Ti Nr&pacity1rado �L No. Compartments 4,f IPKG. TREATMENT PLT. ❑' � ++ ys R �3��}' '' Method of Disposal i Distance to nearest: Well ��Founclation �. °F z- Property Line, 1-1 t LEACHING LINE X No.'& Length•of An 1162�©_�� Total length/size :t i^ I FILTER BED ❑ Distarice'to nearest: Y Well 0 r Foundation .Z.�f'T"PropertV,Ciffg-_—T SEEPAGE PITS Depth' 2,6" 7' Size _ `8 �N7L)/-4Numbertil J SUMPS'."" F] Distance to nearest: Well t�_T Foundation��TPro_perty-Line. 13 FT Wit- 'DISPOSAL'PONDS ❑ � I �s I hereby certify that I have prepared ails'application and-th'at the work�wi]I be`done-in'accordance wiih�San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local.'HeaIfh District. =V�, 0 -1 1 r 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 this following:"I certify that in the performance of the work for which this permit.Is.lssued, I shall employ persons subject ta`worKman's`corimpensa- .a tion laws of California.' �% % �.� � .,V.- �.� •�� •" 1 The applicant must call for II requi d inspe- tions.`Cyomplate drawing on reverse side. Signed X` �+� o �+ Title: Date: 4 FOR DEPARTM N US`E O LYt--" Application Accepted by L D e 7~Q Area Pit or Grout Inspection by Date Fin n ectinn by -�� Dated Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i 4 j E 1 FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT'NO. INFO CASH i + EH114-26 3-24 IREV.10/83) Lis ea o �o s 3 � �^—<A s1