88-495 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE_ STOCKTON, CA Telephone (209) 466-6781 .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k (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. 4862 for well pump and the Rules and Regulations of the San Joaquin Local Health District. 3518 Munford City Stockton Lot Size 'PM Job Address Linda Todd Address 4920 South Kingsley phone 94,8-441 Owner's Name . 2024• E. CharterWay 377.560 1PllOne 462�767b Contractor Clark Well t� Address � License No. t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1DESTRUCTION11 PUMP INSTALLATION)0 SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES p DISPOSAL FLD. PROP; LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS r � � i INTENDED USE TYPE OF WELL PROBLEM AREA COrNSTRUCTION;SPECIFICATIONS a . .-,o.. _ _ ._ ,� ...Dia.'of Well Casing ❑ Industrial -❑ Open Bottom ❑ Manteca Dia. of 1+17e11�Excavatron r r Type of Casing Specific�tiohs i ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Grout — r f l Public ❑ Other Cl Delta Depth of Grout Seal k I I Irrigation __Approx7Depth I I Eastern Surface Seal Installed by Installed ( ' r Sub H,P. 1 . 5 State Work Done Repair Work Done ❑ Type of Pump rfj Well Destruction Ll Well Diameter Sealing Material (top 50'1; Depth rT Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION l l , DESTRUCTION ['1';(No sbptic within tftm, rmi' e�if publi;se�eris 11 (�J� q..w�•wn-ww.1`+ +r'w.w•r�rnwr+ 1 M Installation will serve: Residence Commercial_ Other ; Number of living units: Number of bedrooms F Character of soil to-a-depth of 3 feel; a W ter table depth t_ CapIT acityN6. Compartments 4 SEPTIC--T-ANK — ^^--E].-°Type/Mfg- _ - PKG. TREATMENT PLT. L1 xy Method-of Disposal 1 Distance to nearest:] Well Foundation , Propey Line i� f s r Total-.length/size LEACHING LINE. ❑ No. & Length of lines�; - 1 FILTER BED Distance oto nearest: ;1lVell 3� 'F dation Property Line k ; t SEEPAGE PITS # I'], Depth I Size Number F SUMPS ❑y Distance nearest: Well Foundation Property Line y~_ t DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county�6 na_es, statel laws, and rules and regulations of the San Joaquin Local Heatth District. 't ' Home owner or licensed agent's signature certifies the following: "I certify that,in the performance of the work for which ng or's6b- 1s issued; I shall notes" employ any rson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature t certifies th f owing: " certify that in the performance of the work for which this permit is issued, I shall employ persons subjeo workman's'cornpensa i tion laws C jifornia The applica ust ca q IT s cti s. Complete drawing on reverse side. Title: Sec-Tres Date:I; 2 6 Feb 188 Signed X ' FOR EPARTMENT USE ONLY t� •: f Date r Application Accepted by t Pit or Grout Inspection by Date Final Inspection j+ + Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,•P.O. Bax 2009, Stk., CA 95201 t FEE CK RECEIVED BY DATE PERMl7'ND. AMOUNT DUE AMOUNT REMITTED CASH INFO + EH 13-241REV.5/N E7 EH 14-2e r _