88-648 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT V 1601 E. HAZEL T Ofd AVE., STOCKTON, CA •.* =Y !! Telephone (209) 466-6781 i� PERMIT EXPIRES TYEAR FROM DATE ISSUED (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. Job Address ` ` 7 ^ s 4` 11V-r /4009City 7 Lot Size '✓ PM Pei Owner's Name ./ , _.rye` Address T 110A Phone AqAa6e s Contractor" Address/ V .r a License No.,3723 Phone ."TYPE OF WELL/PUMP: ;p. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 12 DISTANCE TO NEAREST: SEPTIC TANK " Z'00- SEWER LINES DISPOSAL FLD. PROP. LINE O FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO r� ❑ Industrial ©Open Bottom ❑ Manteca Dia. of Well Excav n Dia. of Well Casing 6' i,❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications Public C1,Other Delta Depth of Grout Seal 1 V© Type of Grout +�C - I ©� � � Py.T �l I ! Irrigation Approx. Depth I 1 Eastern Suri ce Seal Installed by - Repair Work Done ❑ Type of Pump 4 P- H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC"WORK: NEW INSTALLATION {1 REPAIR/ADDITION l 1 DESTRUCTION { I (No septic system permitted if public sewer is C available within 200 feet.) Installation will serve: Residence— Commercial_ Other (A 4 Number of living units: Number of bedrooms Character of soil to a depth} of 3 feet: Water table depth I SEPTIC TANK ❑ i� Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal II Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ I, No. & Length of lines Total length/size FILTER BED ❑ i' Distance to nearest: Well Foundation Property Line {� ' SEEPAGE PITS 11.1qq Depth Size Number SUMPS L-i 11 Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have pFeparad 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, 1 shall not`f employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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- C, tion laws of California." ;. The applicant must all ffoorr all�red inspections. Complete drawing on reverse side. Dp .Signed X._....__..._dcl��. '� � __ Title: yrs"'%- _ Date: I� FOR DEPARTMENT USE ONLY N Application Accepted by Date -1 Area T Pit or Grout Inspection Date ` ,Final Inspection byly Dat Additional Comments: Q 4JB l"I 111;"`u1,[_(s.t- 2 Grp.t/h tj�r GYM�r ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 623-7144 ❑ Tracy 635 f385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E..Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO p ! + EM 13-24(REV.I/n 5) EH 14-28 II