2685 - Laserfiche WebLink

Home Browse Search

K APPLICATION FOR PERMIT n SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA V IIJJ Telephone 12091 466-6781 b 1988 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 1�+, ;tiTAL N4!�LT4l t; AVOU c�r��VIC�s Application is hereby made to the San Jdaquin Local Health District for a permit to construct and/or install the work herein R In. RtIs 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 Dist" t. R _ ra Job Address v City k t Size PM Owner's Name +�,� Address O ' •, ""� PhoneY4-�- LL— ZContractor LAddress D� 64qgk�icense No? 13�� Phone G 1— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTR CTION ❑ PUMP INSTALLATION SYSTEM REPAIR Ll OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE s FOUNDATION — AGRICULTURE WELL aTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specificationsi `•.3 i`1 Public ❑ Other p� 171Delta Depth of Grout Seal Type of Grout' 11 Irrigation _-.Appfox, Depth I. I Eastern Surface a'I Installed by Repair Work Done ❑ Type of Pump Q_-.— H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 # ! Depth I Filler Material tBelow 50'1 i TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION f I DESTRUCTION I 1 (No septic system permitted if public sewer is ZZ available within-200 feet-)-- Installation eet-) ---Installation will serve: Residence __ Commercial Other Number of living units: Number of,badrooms Character of soil to a depth of 3 feet:{ Water table depth ` SEPTIC TANK ❑ Type/Mfg ;Capacity' ry No. Compartments PKG. TREATMENT PLT. L1T_^J Method of Iisposal Distance to nearest:" Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size s FILTER BED ❑ Distance to nearest: Well Foundation Property Line --_— SEEPAGE -- SEEPAGE PITS 11 Depth I Size Numbert— + r SUMPS L-I 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 licensed agent's signature certifies the following:•."l certify fhat in the performance of the work lcir which this permit is issued, I shalt not a owne^employ any er n in su nner as to become-subject to�workman's,compensation laws of California." Contracfor's hiring or sub-contracting signature certifies the oil ing: " ce y at Ge mantaf,!hte work forwhI-h this permit is issued, I shall employ persons subject to workman's compensa-tion laws of Cal ornia."The applic te a uirns. Ce drawing on reverse side. D` ►..-.w.e.�.-,.,�.-- Jia. Signed X Title: s[�L�� Date: / : ORD A ENT-USE ONLY x Application Accepted by �-•Date. �( Area t 1 Pit or Grout Inspection by Date'..c -4 f1 Finbl jns. a�by ' Date///19;g Additional Commants: 3 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Saturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE-7 PERIVIIT'NO. +.Err 13.24(REV.i/n 5) EH 14-26 i