88-61 - Laserfiche WebLink

Home Browse Search

x " F APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICTS - 1601 E. HAZEL T ON AVE., STOCKTON, CA - ! Telephone (209) 466-6781 �• . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ (Complete in Triplicate) ` Application is heieby made to the San Joaquin Local Health District for a permit to construct and/of 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 Address /74. Cit - City A Z/Q Lot Size PM Owner's Name PAT- Address Lt/�71 7 Phone 7— Contractor Contractor�'r� Address f � / �L .. ��` License No.4 / Phone TYPE OF WELL/PUMP: NEW WELL;0 WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ,�0 r SYSTEM REPAIR ❑ OTHER ❑ k DISTANCE TO NEAREST: SEPTIC TANK 4 ZOO ► SEWER LINES DISPOSAL FLD. _FOUNDATION PROP. LINE rAGRICU r i j WELL OTHER WELL ��" PITS/SUMPS � t— " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca "bio, of Well Excavation pia. of Wel! Casing Domestic/Private �rGravel Pack Y❑ Tracy -Type of Casing �/t! M Public ❑ Other Specifications C[ /611) -. r ❑ Delta Depth of Grout Seal OK -t Type of Grout_Gd ale fad I I Irrigation t72°L�jApprox,,Depth I Eastern Surface Seal Installed by X)/.J Repair Work Done ❑ Type of P m r l S y�� p H.P. State Work Done, Well Destruction ❑ Well Diameter;� Sealing Material (top 50') Depth . Filler Material (Below 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADD(TlON !.I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence t Commercial -- Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg PKG. TREATMENT PLT. C1Capacity No. Compartments Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines i FILTER BED ❑ Distance to nearest: Total length/size Well �- Foundation Property Line SEEPAGE PITS f I Depth Size i Number SUMPS ❑ Distance to nearest: Well Foundation "ti DISPOSAL. PONDS ID Foundation Line rules and regulations of the San Joaquin Local Health District. 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 Home owner or licensed agent's signature certifies the following: "I certify that in the perlormance)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 Califoinia." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject u workman's compensr l tion laws of California." The applican f allre spections. Complete drawing on r vers s' e.- Signed X_J� ! ///� i,�. � Title: / Date: FORD PARTMENT USE ONLY Application Accepted by Rate Area Pito Grout inspection by Date Jg C� Final !ns tion by Date Additional Comments: —/ �_, ❑ Stk 466-6781 El Lodi 369-36210 Manteca 823-7104 ❑ Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200Stk., CA 9 1 FEE AMOUNT DUE AMOUNT REMITTED CK INFO { CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.',/N sl-EH 14-26 os } rr