88-3054 - Laserfiche WebLink

Home Browse Search

4 APPLICATION FOR PERMIT PAYMENT JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 OCT 3 -11988 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 1UPU�� ..®� {Complete in Triplicate) ENVIRONMENTAL HEALTH I 5P�NJ\� ��' PdR N�ITISfAVIC15 Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein descri a rs app ication 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. Job Address Z9�._ >�J� 1�p� CityS Lot Size PM Owner's Name �L WAIVAddress .s Fig; 2&.4. �•�'; '��d --- Phone -/Aec- 49WWf,&A&firmst_ 30 T9- SuN1-)SE0-1140• Contractor_,f4eyi c Address NC v fo License No. 611 7 Phone -46 -8a TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL 500 ",_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fad�l oatj prif►/ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �f- © Domestic/Private •�JJ Gravel Pad ❑ Tracy Type of Casing vG- Specifications ❑ Public 7 Other ;r( Delta Depth of Grout Seal 3 Type of Grout - 1 1 irrigation �rApprox !Depth I 1 Eastern Surface Seal Installed by e/ Yt3Y!/�f +�� G k Repair Work Done ❑ Type of Pumpilll AMNIZ H,P. _,Q/ /J State Wor Done Well Destruction 0 Well Diamew �� - Sealing Material Itop4m S Depth r�-6 f Filler Material iBel�) Y, TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 1 DESTRUCTION I 1 1No eptic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial' Other Number of living units: Number of bedrooms - Character of soil to a depth of 3 feel:I Water table depth � SEPTIC TANK ❑ Type/Mfg, Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance'fo nearest: Well Foundation Property Line i Total len th/size LEACHING LINE ❑ No. & Length of lines 9 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth I Size Y Number _Sl1MPS Ll to nearest: Well Foundation Property Line IDISPOSAL PONDS ❑ a - a -.. �.w 4 .::-:.. , . a. ��:.== -�:. �. :,, .m - — I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San Joaquin Local Health Di?trict. 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 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 gwst call for all re uired inspections. Complete drawing on reverse side Signed X Title: fN e'rl Date: IO �� 4 fi FOR DEPARTMENT USE ONLY V ;.. Application Accepted by Date s Area j Pit or Grout Inspection by Date Final Inspection by �' ' ` Date /"��- ' Additional Comments: ^" ' w, F ❑ Stk 466-6781 ❑ Lodi 369-3621 © Ma ica;. 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., PA. Box 2009, Stk., CA 95201 ' 1 FEE AMOUNT DUE !�AN/1 UN's REMITTED CASH RECEIVED BY DATE PERMIT•NO. - INFO _ - fREV,r1"51 . ��4 FLS V r