88-2277 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT b �, ;• SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA .�• Telephone (209) 466-6781 a PERMIT EXPIRES 1 YEAR 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. I cvzL q P)+ /,] q 1 { Job Address✓ ,`)r4 yy ?, )PJik1_tW City Z-0 �r' Lot Size Alkf a PM Owner's Name G L r r3ip 7 Address -SAAR 1' Phone s j 7 Contractor*000 Address 7e&O f h r 1 r4A 4h1 L"V License No.4i/1993'4 Phone Off/3�J r y f TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _ a SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ' AGRICULTURE WELL OTHER WELLry PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ ❑ Industrial °` ~~❑ Open Bottom '" O.Manteca Dia. of Well Excavation _ Dia.•of Well Casing S ❑ Domestic/Private WGravel Pack Tracy Type of Casing A �� Specifications ('1 Public F] Other ❑.Delta Depth of.Grout Sea! 06 g /ff dfe Type of Grout Nthw_ I I Irrigation 11AApprox. Depth I I Eastern Surface Seal Installed by Saew.SF_AC_ _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Wel! Destruction ❑ `W- 0') Weil Diameter Sealing Material (top 5 i �'rillActlidwW".pth Filler Material {Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/fJlfg T Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number f,. SUMPS ❑ 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 District. 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 r 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 alifornia." tel. 1 The app , must call for r required'ins c.' ns. Complete drawing on erse side. Signed XMIZ Date: 7/� "-- O I FOR DEPARTMENT USE ONLY Application , cepted by )/ Date ` r Area Pit or Grout Inspection Date �V Final Inspection by AieAAA Date 4 Additional Comments: ❑ Stk-466-6781- ❑ Lodi„369-3621. .,,❑ Manteca- a23-7104 --.-0 Tracy 835-6365• k Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEI INFO AMOUNT DUE s AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. i +.EH 1324lREV.1i851 EH 1428 f