88-2177 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT, 1601 E. HAZELT ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR 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 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. y I t Job Address ,'`, . City Lot SiXo_x � PM Owner's Name wi Address Phone p '' `` '' .; o % s5,�- . W}��PL�,� I �0. _.. �.LO!� 3 Qo Phone Contractor Address �' License No. TYPE OF WELL/PUMP: NEW WELL ❑ 'r WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ `. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ; SEWER LINES DISPOSAL,.FLD. PROP. LINE k, FOUNDATION AGRICULTURE WELL OTHER WELL- _ PITS/SUMPS _ INTENDED USE TYPE OF WELL t PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ I e ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well.-Casing ❑ Domestic;Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i n Public Cl Other ❑ Delta -Depth of Grout Seal Type of Grout T I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by r _' Repair Work Done Q Type of Pump I H.P. ' State Work{Done_ 4 Well Destruction ❑ Well Diameter Sealing Material (top 501 ;•—Depth 1 Filler Material (Below 50') TYPE OF SEPTIC'WORK: [NEW INSTALLATION U,�lR/ADDITION I I DESTRUCTION 1!1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:"' Re ence�"^~'C ommercial- Other Number of living unite_ Number ofbedrooms t Character of soil to a de_p3thtof feet Water table depth SEPTIC TANK 5?L_Type/Mfg acity` _ No. Compartments PKG. TREATMENT PLT. ❑ Ito(,X-6 Ca Method of Disposal ' Distance to nearest: We Found '4n-•- Property.Line LEACHING LINE 61/q,. a Length of lines Total length/size FILTER BED CJ Distance to nearest: Well Foundation. `{ Property Line _ SEEPAGE PITS -%Ft;O -eepth Size X2D Number SUMPS tance.to riearest: Well Foundatlon,J&S Property Line DISPOSAL PONDS ❑ 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 t 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, I shall employ persons subject to workman's compensa- t` 'o Fa of Califor ' s- I The applicant t call fo all req ed i mple drawing reverse ide. r Signe > Title: � Date: FOR DEPARTMENT USE ONLY GC Application Accepted by Date QQ Area 1 Pit or Grout Inspection by Date- �-� Final Inspection by, � DateO- 67 ,,. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 yy ! Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 gj i FEE' - AMOUNT DUE'-t"` AMOUNT REMITTED :r CK. RECEIVED'BY ---DATE" -PERMIT'NO. INFO ��j / -`CASH a.EH13-24itiEV.t�N51 ��iJ y✓ 'Y tr. > y �� l ' EN 14-28 �/