88-3329 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 466-6781 PA Y-M PERMIT EXPIRES 1:YEAR FROM DATE ISSUED "CEI VED 1 (Complete in Triplicate) FF((�'' ] Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herreeifTdescFi dI91application 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 Locale Health:Distract:. FNV1 HE RONMENTAL ' AL F `A 'ERMIT/SERVI LTH Job Address. *• i City �- Lot Size (jam Owner's Name G�( f�'YJL( 4�if2'11Z Address Phone .. ] J r E n I Contractor cense No. - ;&?05'/3 Phone 11F TYPE OF WELL/PUMP: NEW WELL )e WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK __/00.-_-.- SEWER LINES. DISPOSAL FLD. /00 PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE "TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial -`❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing til Domestic/Private X Gravel Par ck [X Tracy Type of Casing rSpecifications 11 Public U Other ❑ pelta 4 Depth of Grout Seal Jf17"1 Type of Grout Q --T�-�1 I i Irrigation --_Approxi Depth I I Eastern Surface Seal Installed byd Repair Work Done Elm Type of Pup H.P. - State Work Done _ Well Destruction ❑ Well Diamoter Sealing'Material (top 501 Depth i. Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is f. available within 200 feet.) Installation will serve: Residence 4 Commercial Other Number of living units: Number of bedrooms y Character of soil to a depth of 3 feet; Water table depth SEPTIC TANK i. ❑ Type/Mfg_ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �i Distance to nearest: Well Foundation Property Line k y LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: well Foundation Property Line f SEEPAGE PITS. I'I Depth ' Size Number i SUMPS L-) Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS El----=- 1 ------:1 hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin county ordinances, state laws, an + rules and regulations of the San Joaquin Local Health District. f 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 law's 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."- 1 The applicant ust call for all requirgy inspections. omplete drawing oaverse side. Signed X Title: Date: t FOR DEPARTMENT USE ONLY Application Accepted by _ ` Date !�� Area Pit or Grout Inspection by Date-1 9q _ Final Inspection bi Da Additional Comments: lit/ rnu /0 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma6leca 8217104F racy 835-6985 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED f�C�A//SHq 2 RECEIVED BY 1 DATE CK 0 PERMIT No. +.EH 13 2 IREV.t i K 51 - O / �`"� ry mac;— EH 14-28 // U