88-3117 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT (7 �* T. SAN JOAQUIN .LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Jo a Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin rnty rdinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health D " a� Job Address yj7y��dlhf E Gity S'Td�Lot Size ��D X 1r PM Owner's Name �/� ��-T�AAD e Address _ Phone 4t7aG 43 ^ Contractor_�a:1 6• w�Address 3�27` License No. 7�1'Y74 -PhoneS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 6 , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE N FOUNDATION--AGRICULTURE WEL-L—==L ""'OTHER WELT -w _ ` PITSISUMPS C�} I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bott`oni•"--C] Manteca Dia. of Well Excavation Dia. of Well Casing _ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f-1 Public 17 Other 11=1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth - Filler Material (Below 50'1---- = TYPE OF SEPTIC WORK: NEW INSTALLATION_I_I;,,•,•REPAIR/ADDITION i l DESTRUCTION ] (No septic system permitted it public sewer is + - - available within 200 feet.I Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms ,. f Character of soil to a depth of 31eet: `- =' t Water table depth SEPTIC TANK i7 Type/Mfg r� • Capacity No. Compartments .� f PKC. TREATMENT PLT. ❑ Method of Disposal� Distance to nearest: well Foundation Property Line I t LEACHING LINE ❑ No. & Length of lines _- Total length/size FILTER.BED ❑ Distance to nearest: Well Foundation Property tine . -. i � t SEEPAGE:PITS rI I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 District. Home owner or licensed agent's signature certifies the following: 'y l certify that in the performance of the work for which this permit is issued, I shall not %r employ any person in such manner as to become subject to' orkmah'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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X 7�3 Title: Date: FOR ARTMENT USE ONLY Application Accepted by h� Date Area f Pit or Grout Inspection Date Final Inspection by _ Date "- 8� Additional Com nts: 14 Z Cl Stk 466-6781 ❑�L-odi 369-3621 D 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 `°x' •t, I F FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT"IVO. INFO twsK ( 1 � I +.EH 13-24(REV.i/n sl . �j 00 17--0 -- 1 q 1/�/2Sy p G d I I—) I EH 14-26 i f