REMOVAL_1986 - Laserfiche WebLink

Home Browse Search

— APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 mads 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.icr� // p '//� Job Address J,a 00 Ad V Ad, , vAI„4k /C Oci City ` L��+ ) Lot Size PM Owner's Nanta ; wtlk Fn Ur 1 Address ,SSD 3 .SoAL Aw I aA Q4-, S`"-Phone I71wcAxl %1 1191 IV,-'I &rN/../. S loci hw NG.a).9 s &oc-.?12-6-70r, Contractor I {I iia Addressrii'�'f dM p f d/l License No. 40 253. Phone -W 1115 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X G DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS X11) El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation \O Dia. of Well Cassa Y ❑ Domestic/Private X Gravel Pack ❑ Tracy Type of Casin1ltJ Specifications ❑ Public % Other&M v� cry ❑ Delta Depth of Grout Seal Type of Grout 501/* ❑ Irrigation JCS-'Approx. Depth ❑ Eastern Surface Seal Installed by a Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 509 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (7 DESTRUCTION ❑ (No septic system permitted H public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other----- Number ther ____Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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. 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 laws 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." The applicant call al `d inspections. Complete drawing on reverse side. SignedTitle: /�/�✓$�� Date: D A T USE ONLY Application 2lntk b Date - - Pit or GroutDate�[�/�1�'Final Inspectlgn by DataAdditional C : rS ❑ Stk 4688781 ❑ Lodi 3W362V ❑ Manteca 823-7104 ❑ T41cy Applicant- Return all copies to: Environmental Health Permit/Services feet E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 :FEEEAM;OU:NT�DU;E AMOUNT REMITTED .A RECEIVED BY DATE PERMITNO. EH 14]91RFV.riB5) �• �'�� I��j �\ ��LS/ _ Z ��1. 07l,�