93-0505 - Laserfiche WebLink

Home Browse Search

w APPLICATION FOR PERMIT 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) This Application is hereby made to the San Jocation is aqui Ofd Local oe No.549 for sewage or permit No. 1862 for well/dpump install nd the Rules and herein Regulations of the San r Joaquin made in compliance with San Joaquin County Local Health District. (,�� �e lv City CA Lot Size PM . Ur Job Address Phone • f C Address Owner's Name n R� /� ` & r�(A :-7�b jq C1a�( License No. •�u� S� -Phone .tom Contractor (ti r I Address DESTRUCTION Cl NEW WELL WELL REPLACEMENT ❑ OTHER ❑ 1 TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ 0 PUMP INSTALLATION>� '� - ' !. �-�171 DISPOSAL FLA. PROP. LINE Zb I SEWER LINES ---� PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK —L�-- • `- .. OTHER WELL FOUNDATION AGRICULTURE WELL tl TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S IN Excavation Dia. of Well Casing Dia. of Well - ❑.Open Botiom ❑ Manteca IN ❑ Industrial Type of Casing a Specifications 'J r Gravel Pack ❑ Tracy Type of Grout [1 �-1— DomesticlPrivate .R ,.,,,, Depth of Grout Seal j'pp l f 1 Ot r Cl Delta t = > M 1 Public Surface Seal installed by _ I I lrrigation �•� pprox. Depth l I Eastern „� •I State Work Done — H'P� ► Repair Work Done ❑ Type of Pump Sealing Material (top 50) Well Destruction ED Well Diameter �— r Depth Filler Material lBelow•501^� 'avaifdble within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRI�ADDITION l l DESTROC TION 4 I (No septic system permitted if public sewer is installation will serve: Residence—�Commercial .�',VOthe 'r 3 Number of living units: Nurriber`of bedrooms ) l } I 3 I # , ----�---^y^ Water table depth n Character of soil to a depth of 3 feet: 5 Capacity ` No. Compartments V SEPTIC TANK ❑ Type/Mfg Method of Disposal ' i ! 1 PKG. TREATMENT PLT. ❑ Foundation Property Line 1 Distance to nearest: Weil I Total length/size LEACHING LINE ❑ No. & Length of lines Property Line k ❑ Distance to nearest: Wel! Foundation p y FILTER BED ' fSize Number SEEPAGE PITS 1 I Depth } Foundation Property Line SUMPS Ll Distance to nearest: Wel!T�i " DISPOSAL PONDS ❑ 7 . '� ", 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, an rules and regulations of the San Joaquin Local Health District.g for Home owner or licensed such manner is signature to become subjectf following-, wng-, "I certify that cation laws n the pertoof California•"Contractor's rr''slhiringt or sub-contracting fsignlature employ any person certifies the following: "I certify that in the performance of the work far which this permit is issued, k shall employ persons subject to workman's compen sa- tion laws of California." I .cant u t call for all required ins tions. Comple drawing on reverse side. � 2�.R2 Th app Title: Data: Signed X '` FOR DEPARTMENT USE ONLY f C7 l� Area Date Application Accepted bye- - - - Date I Date Final Inspection by:: i Pit o Grout I pection by �d:�� Additional Comments: ❑ Stk 46b 6781 di 369-36.21 Manteca 823 7104 ❑ Tracy 835 4 vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 51k., CA 95201 Applicant Return all copies to: En r CK RECEIVED BY - DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH 'F INFO - - I +.EH 13.24(REV.i/n 5) I EH 14-26 __