88-1403 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTD Cao 1601 E. HAZEL T ON AVE. STOCKTON, CA 209 Telephone p c ! ass-s7$1: J U N 1 X988 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) ENV1RdMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work Ifi rreiinMas Vt4 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. plication is s < ' Job Address ` Cit P Lot Size aelil PM ),.�'OWner's-Name. . c Address ; Phone Contrac l� Address f T«< 3��ZZ�S TYPE OF WELL/PUMP: License No- �_ phone NEW WELL' ❑ " WELL REPLACEMENT ❑ 'DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El`^ OTHER ❑ r- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f -' ` _ DISPOSAL'D. FOUNDATION PROP. LINE AGRICULTURE WELL T `'Y - - i OTHER WELL PITS/S-MPS �_. _ - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ❑ Domestic/Private D Gravel Pack Dia. of Well Excavation Dia. of Well Casing I E •' LD �� Type of Casing � - M Public ❑ OtherCl Delta Specifications Depth of Grout Seal Type of Grout I i Irrigation �_Approx. Depth I ! Eastern R Repair Work Done El T Surface Seal Installed by Type of Pump - H,P. State Work Done Weli Destruction 13 Well Diameter Sealing Material (top 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATDepth t "I Filler Material (Below 5011 ION I i REPAIR/ADDITION isT DESTRUCTION l 1 1No septic system permitted-if public sewer is . Installation will serve: Residence ✓ Commercial ,: [ available within 200 feet.) Number of living units: Other pp Number of Brooms t\$ Character of soil to a depth of 3 feet: SEPTIC TANK - , Water table depth 4 L/Type/Mfg Capacit _ � �t PKG. TREATMENT PLT. ❑ No. Compartments , Distance to nearest: WeII J( r A Method of.-Disposal Foundation—_L<J�_�,Property Line "=ti LEACHING LINE. llYNo. & Length of lines , ® �. _ FILTER BED ❑ Distance to nearest: WellFoundatTotal length/size , ion �--- Aroperty Line SEEPAGE PITS .p. I I Depth Size ® _ SUMPS N. ur mberistanceto�nearesr ^ eIII1nnr -FoundationDISPOSAL PONDS _❑ rQ. property Line__aS 1 hereby certify-that I have prepared this application'And that the work will be done in accordance with San Joaquin county ordinances ` rules and regulations of the-San Joaquin Local Health-'District. state laws, and —Home owner or licensed agents signatuie certifies the following: - -- - {n employ any person in such ma fy tha an'to become subject-to workman's compensation lawsofCalifonce miahg Contractawork for x_s!hhinet oAsub-contracting lsignaltu�e rt'1 i ceitifies the following: "I certify that in`the performance of the work for which this permit is issued, l shah employ .-tion laws'of-Califorriia.-"-._•--.n r. Persons subject to workman's compensa- ' The applicant ust call f It r fled inspections. Complete drawing on reverse si Signed X .Title: Date: f- FOR DEPARTMENT USE ONLY Application Accepted by , r { Date Area Grout Inspection by / D` "I Da Final Inspection by . dditional orpfnents: ,-. �, t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385v A !j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,'O. Box 2009, Stk., CA 955201 j FEE AMOUNT DUE CK. INFO AMOUNT REMITTED RECEIVEp gy 1 �7 CASH -- RATE PERMIT'NO. + EH 13-24 IAEV.1 i A s1 /� EH 14-26 _ (,�