88-951 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA " Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he€eby 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. Job Addressl cf `'• 1 L?t S i�!l �J ie City Lat Size. � C PM Owner's Name Dsi� Address L lie "Phone Contractor .,4�z _Address' -.../..A; fes, L icense..{Vo.:o12r �2 .Phone TYPE OF WELL/PUMP:. NEW WELL ❑ '%WELL-REPLACEM' ENT..❑ DESTRUCTION-0 '*..t, PUMP INSTALLATION ❑ 9.. SYSTEM REPAIR ❑ OTHER ❑ DISTAAICE TO NEARESTSEP TIC TANK SEWER LINES ' �" DISPOSAL FLD. POOP. LINE :. FOUNDATION ,^+R AGRICULTURE WELL OTHER WELL PITS/SUMPS'` I INTENDED USE TYPE OF WELL FIR BLEM AREA�-'�•CONSTRUC7ION SPEGIFtCATIQNS� `, R ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well C �. -171 Domestic/Private ❑ Gravel Pack ❑''Tracy ype of.Casing: -- -Speciikcations 1-1 Public F1 Other '., 177 pelta "5= Depth bf-Grout Seal i",4 - -- -• Type�1F out I ! Irrigation _.Approx. Depth I I Eastern Surface Seal installed by A Repair IVork Done❑ -Type of Pump H.P. St`t'e Work Done i Well Ddstruction ❑ Well Diameter Sealing Material,ltpp 50'j Depth._Y,, -# Filler Material (Below 501+ r.. ~ I F I TYPE OF SEPTIC WORK: NEW INS, ALLATION; • REPAIRIADDITION I I DESTRUCTIOW;ri' (No septic system permitted if public'sewer is" available within 200 feet I Installation will serve: 'Residence mercial_-Other Numtier of living units: _/_ Number of bedrooms s: Character of soil to a depth of 3 feet Water table depth ' to F tit r SEPTIC;TANK 14 Type/1111g� P 9 z -Capacity-Q060".41 &No. Compartments; + ' PKG. TREATMENT PLT-. ❑ , Method of Disposal! ' 11 _Qistanee*to nearest: Well f F Foundation`1[QProperty Line i E LEACHING LINE ] No. 8 Length'of lines _Total length/i ize r 1 FILTER BED ❑ Distance to nearest: Well Foundation- .Property Line Y SEEPAGE PITS l I Depth f Q' -Size j� _ Number SUMP '- y7 Distance to nearest: Weil_jtl � Foundation Property Line # ! I DISP05AL`POfVD'S' jr'�{❑ # I hereby certify that I,have prepared this application and that the work will be done in_accordarice 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 fo'llowin`g: "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 became subject to workman's compensation laws of California.",Contractor's hiring or sub-contracting signature certifiesthe following:"I certify that in i6o performance of the-'-work for which this permit is issued,I shall employ persons subject.to workman's compensa- tion laws of California." � a The applicant must call for all re ire d nspections. Complete drawing on reverse side. SignedlX Title: t'!dpe „t Dade: "FO� EPARTMENT USE ONLY � t IJ 1KL /Application Accepted by "' Date, Area /{ Pit or Grout Inspection by Date Final Inspection by E Date E I Additional Comments: ' ❑ Stk' 466 6781 E3Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-6385 i AppliclInt- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 ' E I , FEE 1 INFO AMOUNT DUE AMOUNT REMITTED "CASHCK 0f RECEIVED BY DATE PERMIT'NO. - - mar . • ' '+ EH 13-�4 IREV.-i!"n`sf «'<'�'`.. _.°" """'�"..-"."„"' f "� •� { �—•--,.. EH 1429