88-571 - Laserfiche WebLink

Home Browse Search

fl '� APPLICATION FOR PERMIT 1. SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZELT ON AVE., STOCKTON, CA Telephone (209) 466-6781 IPERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) r sewage a or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local No.549 for ser agpermit to construct and/or install the work herein described.This application is made in compliance with San Joaquin Conty ordinance Local Health Dist 15G I W . �.�l-k C�pxN a{'cV City 5tkti Lot Size '�ZSO PM Job Address Phone Address 4f3_ 3o Address !!��Owner's Name$pcPT1S�T [k}Vi�li '"�� F�fa.P `i6.53 Phone—License No.__33—��— Contractor_� � WELL REPLA EMENT 11 DESTRUCTION ❑ TYPE OF WELL/PUMP: . NEW WELL IJ WELL 1-1PUMP INSTALLATION ElSYSTEM REPAIR ❑ SEWER LINES _�— DISPOSAL FLD. ROP. LINE DISTANCE TO NEAREST: SEPTIC K OTHER W PITSISUMPS FOUNDATIO AGRICULTURE WELL i TYPE 01"� VELL PRO EA CONSTRUCTION S (CATIONS w INTENDED USE f W cavation Dia. of Well Casing c ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications - ❑ Tracy T of Casi ❑ Domestic/Private L] Gravel Pack F1 pelta Depth of Grout Seal Type of Grout alled by f`1 Public H P Pump n Other g Appro Depth l 1 E rn Surface Seal Inst I I Irrigation — State Work Done Repair Work Done ❑ Type of Pup 'r Sealing Material (top 501 Well Destruction ❑ Well Diamo --- Dep Filler Material (Below 50'1 y septic system per available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALtJ4010N I:1 REPAIR/ADDITION i ! DESTRUCTION av mitted if public sewer is Installation will serve: Residence Commercial.— Other��— k- j Number of living units: •'Number o1 bedrooms Water table depth i Character of sail to a depth of 3 feet: _ Capacity � � No. Compartments Y SEPTIC TANK Type/Mfg Method of Disposal 1 PKG, TREATMENT PLT. ❑ � A Property Line I Distance to nearest: Well Foundation l y. Total length/size LEACHING LINE ❑ No. & Length of lines PropertyLine 'i Foundation` \ FILTER BED ❑ Distance to nearest: Well Number SEEPAGE PITS C I Depth1 Size Property Line SUMPS L� Distanfsce to nearest: Well Foundation r DISPOSAL PONDS ❑ I nd that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application a rules and regulations of the San Joaquin Local Health District. that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following:."I certifyor nature employ any person in such manner as to become subject to workman's compensation Yaws of California." Contractonsrsub ect to workman1scsign ompensa- certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ PB 1 tion laws of California." i The appli m t call for allr q�dincoons. Complete drawingo averse side. Title: Dater ! Signed X ,t ' r FOR DEPARTMENT USE ONLY r ' Area 4 Date p Application Accepted by Date Date Final Inspection by Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manta 823-7104 ❑ Tracy 835- 5 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, 5tkq�CA 95201 t CK RECEIVED 8Y DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO ) > � + EH 13-24IREV.I/H5l ✓ 1j � Q EH 14-26