88-1139 - Laserfiche WebLink

Home Browse Search

'• i 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 (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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. I ec Job Address MAIN City Lot Size PM Owners Name SE1'GVZ3 Address 13o aL V 1 CAAA let:) Phone ese—q/ Si45" N Contractor I J 1) ` ��r L Address O )c�J S_y- �[�License IVo. �u�! a Phone ! I 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r t I Public M Other n Delta Depth of Grout Seal Type of Grout _ i I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done {` t Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth. P1 Filter Material (Bal w 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.� REPAIR/ADDITION V DESTRUCTION I I (No septic system permitted if public sewer is ,/ available within 200 feet.► Installation will serve: Residence ` Commercial Other f Number of living units: __LJ Number of bdrooms� Character of soil to a depth off 3 feet: Water table depth SEPTIC TANK ❑ Type7IQlf&__Wf=epk+�S� apacrty12-'0—*—NS"CU parth%ftts_ PKG. TREATMENT:PLT--Li , �� '�r Method of Disposal '�] N'Distance to nearest: Well Foundation Property Line S �. LEACHING LINE +, #❑-I No. &Length ofTh6i?s - _ rTotal length/size / FILTER BED Distance to nearest: WeII%SAA Foundation �t ro Pity Ines SEEPAGE PITS Z t<'"q II Depth �l-y' Size ``~ - Number SUMPS ❑ Distance to nearest: 'Well Found tion1 r= 1 Property Line Y, DISPOSAL FONDS- ❑ g f i I hereby certify that I have prepared this application and that the'work will be done in accordance with San Joa�uin county-ordinances, state laws, and rules and regulations of the San`Joaquin Local Health District. `" ^" ,�_ �Y Home owner or licensed agent's signature certifies the following: ".1-certify that in the performance of the work forrwhich this permit is issued,"�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 ormance of the work for.'which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." ft. The applica for all uired ins ctions."Complete drawing on.reverse side. wI Signed X �� -r Title: ` �� r Date: `* ? OR DEPARTMENT USE ONLY Application Accepted.by PQrv. �8 �- -_Date Ss Area Pit or Grout Inspection by Date Final Inspection by Dattrrrw Additional Comments: !26I / _ ❑ Stk 466-6781 ❑ Lodi ❑ Manteca 823-7104 ❑ Tracy 835-6385 ,.Applicant_Return-all.copies-to:'.EnvironJJmental,Health-Permit/5ervices:1601TE.-Hazelton-Ave;-P.0-Box 2009,Stk.CCA-95201-«- .- 1 _ FEE CK INFO AMOUNT DUE AMODUJNT REMITTER ± 'MrCYyAS�H�r EH 141 REC�EIVE�DI9Y DATE PERMI T-NO. + Err 14.-28 24 Ips v.i i K sr /! cam/ �J N