93-0230 - Laserfiche WebLink

Home Browse Search

r �] APPLICATION FOR PERMIT � f SAN JOAQUIN LOCAL HEALTH DISTRICT fJ I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 welUpump and the Rules and Regulations of the San Joaquin ' Local Health District. ,, J Job Address 2 Z 3 5 }- `^ n City f p�14il4 CQ Lot Size 1 Pi cry PM Owner's Name f 10 6_r+ A a Address d 1 014 w a ll Phone 3` Z66 Contractor M4f+A I Address e 011d 6"' 461-icense No. ,2_L..Phone -ems r-TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 117! SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION IDI AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 111 Industrial ❑ Open Bottom ❑ Manteca '" - Dia. of Well Excavation Dia. of Well Casing r 41-Domestic/Private WGrav6I Pack ❑ Tracy Type of Casing C Specifications (l Public ❑ Other ❑ Delta Depth of Grout Seal eft%��irsrType of Grout ( �� IN Irrigation /�pApprox. Depth Irl Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump HS tate W.ork Dong [� Well Destruction ❑ Well Diameter` P Sealing Material (top 501 x\ Depth .v_ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIFOADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is "v available within 200 feet.) Installation will serve: Residence' Commercial. Other r I u J Number of livingunits: Number of bedrooms t. _ Character of soil to a depth of 3 feet:' �% ! t Water table depth SEPTIC TANK ❑ Type/Mfg' y Capacity f No. Compartments PKG. TREATMENT PLT. "'�^`-- F1r"` "' { i +„. �� Method of Disposal \ \ - w__,_ i t j� Distance to nearest: Well Foundation 'i Property Liner 1 LEACHING LINE ❑ No. & Length of lines Total length/size F!LTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 -Depth Size Number SUMPS ❑ Distance to nearest: Well ,Foundation Property Line DISPOSAL PONDS ❑ t I 16reby 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. I Home owher or licensed-agents-signature-certifies-the-following:=-1-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 Caldprrnia."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 C ' ' 4 Tho applica st call for all required inspections. Comple rawing on reverse side. j/�,Q 7 Signedx7- Title: ��'} M _ Date: Z'fy + J O MENT USE ONLY g Application Accepted by Date Ar t—i Pit or rout inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 di 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } INFO E AMOUNT DUE AMOUNT R ITTEO CK H /�RECEIVEp 9Y DATE PER/JMIT'NO. +.EH 13-24(REV.r/x sY "" ` ,/ l i n �r / �y/1 / EH 14-2e / (/�C