89-2084 - Laserfiche WebLink

Home Browse Search

�_ � r'AYMENr,. .. APPLICATION FOR PERMIT RIECjE SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA AUG 2 ... 198g � Telephone (2091 466 6781 ED NVIRONAU G 917989 IERM I� ` HEALTH PERMIT EXPIRES 1'YEAR FROM DATE ISSUED r (Complete in Triplicate) Ef•.Vi , ��> pphcation is sGnbe ��..rr g ump and the Rules and Re�uiations d tlia'�an Joaquin i Application is hereby made to the SanJoaquin Local lne Health 549 for sewaDistrict for a ge or permit 1862 for cwe well/pump install the work herein} made in compliance with San Joaquint{ Local Health District. e� of Size PM �--- City Job Address , L V1; Phone Owner's Name I€) 1 fi �u f, 0 �1/ S f License No.� Phone J` Address Contractor WELL RE LACEMENT ❑ DESTRUCTION ❑ NEW W TYPE OF WELL/PUELL C1 SYSTEM ❑MP: SYSTEM REPAIR ❑ PROP. LINE � PUMP INSTALLATION DISPOSAL FLD. SEWER LINES —� OTHER WELL PITSISUMPS -- DISTANCE TO NEAREST: SEPTIC TANK �— AGRICULTURE WELL FOUNDATION —�-- ON_SPECIFICATION5—_ �... NST.RUCTI ------- INTENDED USE— - —STYPE-OF-WELL_- PROBLEM -AREA--CO Dia. of Well Casing TEN Dia. of Well Excavation IN ❑ Manteca ❑ Industrial ❑ Open Bottom Specifications p Tracy Type of Casing 1�6omestic/Private ❑ Gravel Pack Type of Grout��.--�-- Ci Delta Depth of Grout Seal ('1 Public ❑ Other �1r {" Surface It Installed by 1 I I Irrigation _—"Approk. De th f I EasternState Work Done H.P. Repair Work Done L�? Type of Pump -- —� Wel! Destruction ❑ Well Diameter $— Sealing Material Stop 50'1 Depth Filler Material (Below 50'I available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION i 1 DESTRUCTION i I (No septic system permitted it public sewer Is I �— installation will serve: Residence Commercial— Other; Number of bedrooms Water table depth �� Number of living units: Character of soil to a depth of 3 feet: Capacity�� No, Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal .--� PKG. TREATMENT PLT. ❑ fFoundation� Property Line Distance to nearest: Well I Total lengthlsize LEACHING LINE ❑ No. &Length of lines property Line FILTER BED ❑ Distarice to nearest: Well Foundation—_�— f .1 � i I Depth ' Size Number SEEPAGE PITS Foundation Property Line I Ll Distance to nearest: Well SUMPS aw -- " `�DISFF0SAL PONDS"' r❑— rdance with San Joaquin I hereby certify that I have prepared this application and that the work will be done in accocounty ordinances, state taws, an rules and regulations of the San Joaquin Local Health Di3trict, performance of the work for which this permit is issued, i shall not Home owner or licensed agent's signature certifies the following: "! certify that in the employ any p s the performance subject of the work for which this permit is issued, I shall employ persons subject to workman's compensa- arson 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 Pe tion laws of California." yyy��jjj�� G The applicant call for all requyrled ins ction . Complete drawing on reverse side. Date: v — /-5 / Title: �- i Signed X OR DEPARTMENT USE ONLY } f Date �` "� Area Application Accepted by s r Date Data��—, Final Inspection by Pit or Grout Inspection by Additional Comments: ❑ M�823-7104 ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369-3621 Applicant • Return all copies to: Environmental Health permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009. 51k., GA 9 REGEIVED BY DATE PERMIT N0. FEE AMOUNT DUE AMOUNT REMIT-TED INFO �Z�^'7ii7 +-EH 13.24{REV.tin sl EH 14-26