88-1079 - Laserfiche WebLink

Home Browse Search

r> APPLICATION FOR PERMIT .r �b SAN JOAQUIN LOCAL HEALTH DISTRICT Q`� ` 1601 E. HAZELTON AVE., STOCKTON, CA V Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and/or instalf 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. p G !I Job Address "9-�� a c j +"'r C City IrJLQh'�ot Size PM Owner's Name _ � L�n� Address � Phone Lt J- "� Tiv Contractor_`! �f L,3r,05 AddressJrZJ� " hQ �.ed,,L.icense No. 2408-3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 34 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �SO r SEWER LINES DISPOSAL FLD.�6Z) PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 0&--_.___ Dia. of Well Casing j Domestic/Private 16 Gravel Pack El Tracy Type of Casing_ �[/C1 Specifications y�,, I M Public I.1 Other 171 Delta Depth of Grout Seat �`� Type of G t Ag"T � l- I I Irrigation Approx. Depth 1 I Eastern Surface Seal Installed by T ( L-� _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I 1 (No septic system permitted if public sewer is r� available within 200 feet./ l� Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal rN Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS 0 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 rules and regulations of the San Joaquin Local Health Dt%trict. 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- tion laws of California." The applic nt ust calf for all rSir 'ed inspectio . Complele drawing on T/, se side.' ' �r Signed X tt`kC `l �`f' Title: �0 fu[ Date: Z/:=-- Z. DEPA NT USE ONLY p A� Application Accepted by c C Date 3�Q� Area Pit or mu nspection by Date-j1�_0� Final Inspection by DM0 0. J') Additional Comments: 14 N\_ 'c S ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ; k FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH a.EH 1324(REV.i i H W —7c) , 7c) , O S �! EH 14-29