93-0076 - Laserfiche WebLink

Home Browse Search

{ D APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. }/{/� Job Address Z6 371 f 1► ES eA-hil City Lot Size pM Owner's Name �I &re e v- Address54 r � Phone Contractor M.O r+tm. rO, Address '1 r`Qd r ud DoA License No.3-40� Phone l-0911 V 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4LDomestic/Private.y _L�Gravel Pack ❑ Tracy Type of Casing g Specifications f-I Public ❑ Ot a 1-1-'Delta Depth of Grout Seal t T f , p Type of Groutt� I I Irrigation 'ti -/ _ Approx. Depth-+I-,I_Eastern �LSurface Seal Installed by ; Repair Work Done ❑ Type of Pump ( H P. f Y State Work Done _ Well Destruction ❑ Well Diameter ,Sealing Material-Itop-50'1 Depth' I Filler Material (Below,50'1 1 ��.. I } TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I� DESTRUCTION f I (No septic system permitted if public sewer is t ' !h available within'200 feet.I Installation will serve: Residence f C-ommercial`-__ Other p Number of living units: Number of bedrooms Character of soil to a depth of 3 feet ; Water table depth s , SEPTIC TANK CI Type/Mfg Capacity• No. Compartments $ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest ell"�""'" "-"�Fa ndi§tion Property Line LEACHING LINE 0 No. & Length of lines ; Total length/size y` FILTER BED ❑ Distance to nearest: Well Foundation Property Line t F SEEPAGE PITS 11 Depth Size "' _ Number "� t SUMPS Ll Distance to nearest: Well Foundation 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 M rules and regulations of the San Joaquin Local Health DRtrict. { 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 1 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- tion laws of California." �T The applicant mm s�or all required inspecti ns. Complete dra 'ng on reverse side. Signed X t d[ g _ ills: R DEPARTA11101.1 USE ONLY i p fVL �y k Application Accepted by Date _F `' rea 2- Pit Pit o Gr ut nspection by bat Final Inspection by Date Additional Comments: C1Silk466-6781-3 w odi 369-3621 ❑ Manteca 03-71114 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 w' FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ATE PERMIT'NO. `I tNF01 / 7Z♦.EH 13-21[FEV.tiK51 EH 11-28 T/� t `-{'J `f�� /t � (fU