88-1759 - Laserfiche WebLink

Home Browse Search

f� f t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,. STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Ad " t dress 1 1 "�'"' �- �bN 4VE- - City 11W'F5t Lot Size ZJQ'x��`I PM f R 4 Owner's Name V�sa +�h�Y 1-�� Address !gq2— } a 1 � �1 �£Y r fes__ Phone Z� j Contractor ©WN6E Aur#� Address _ Y License No. Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing I ❑ Domestic/PrivateR ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal' Type of Grout ( I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. 1 State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth I. Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION I I I DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_v Commercial_ Qthet Number of living units: 0 Number of bedrooms V Character of soil to a depth of 3 feet: shockv Water table depth SEPTIC TANK-; Ar, Type/Mfg Capacity �� No. Compartments PKG. TREATMENT:PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines 1D Total length/size - 770 4eA5004Wf FILTER BED -❑- Distance to nearest: Well Foundation Property Line 4© ,1 T SEEPAGE PITS I I Depth 1 Size Number SUMPS LI "Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �.- i hereby certify that'I Crave prepared this application and that the work will be done in accordance%ivith',San Joaquin county ordinances, state laws, and rules and regulations of the San.Joaquin Local Health Drstrict. , _._ -- 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 t 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 applica0pust cal! for"al r quir inspections. Complete drawing on reverse side.' Q Signed X :Title: WFI�-� Date: a f FOR DEPARTMENT USE'-ONLY Application Accepted by f ` = '" +' Date � A •^ rpa Pit or Grout Inspection by \ Date Final Inspection by ✓ Date" Additional Comments:.. 71-al ❑ Stk 466-6781 ❑ Lodi 369;3621 " Manteca 823='7104 ❑ Tracy 835-6U5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.,Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMI7'NO. 70 w~EH 18-241REV.i/H51 r� i EH 14-26 r �` i'