88-194 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT g 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1•YEAR FROM DATE ISSUED (Complete in Triplicate) application is ! sewage No. 1862 for well pump and the Rules and Regulations of the San Joaquin b heiemade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This Application is Y made in compliance with San Joaquin County Ordinance No.54 0 Local Health District. x` City Lot Size Job Address Phone Address Owner's Name. `J � { 44 License No. Phone y ' dress Contractor3 WELL REPLACEMENT 1:1 DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL E3 j49., -�_ / OTHER E) SYSTEM REPAIR PUMP INSTALLATION ❑ ty DISPOSAL FLD. PROP. LINE } ` ' ' SEWER LINES _�----= DISTANCE TO NEAREST:;SEPTIC TANK _1 AGRICULTURE WELL + OTHER WELL PITS/SUMPS FOUNDATION _�•— INTENDED USE _ TYPE OF WELL i PROBLEM AREA- CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Dia. of Well Excavation ❑ Industrial ❑ Open'Bottom ❑ Manteca Specifications a Tracy Type of Casing ❑ Domestic/Private U Gravel Pack Type of Grout +Ll Other LSI Delta Depth of Grout Seal M Public rSurface�Seal-lnstalied by I 1 Irrigation State Depth i I Eastern State Work Done 1 H.P. Repair Work Done C7 Type of Pump Sealing Material )top 50' F �,__.-� Well Diameter �..� ` Well Destruction ❑ Filler Material {Belo ) �q Depth t available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION I.l REPAIRIADDITION DESTRUCTION l i lfJo septic system permitted if public sewer is installation will serve: Residence— Commercial— 'Other—:!— Number of living units: . Number of bedro ms Water table depth C Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK - C7 Type/Mfg _ Method of Disposal PKG. TREATMENT PLT. ❑ ' Foundation�_� Property Line 1 Distance nearest: Well yTotal length/size LEACHING LINE ' ❑ No. & Length of lines t, Foundation Property Line FILTER BED ❑ Distance to nearest: Well I 3 Number SEEPAGE PITS I I Depth Property Line MPS Ll Distance to nearest: Well Foundation �- DISPOSAL PONDS ❑ 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. rules and regulations of the San Joaquin Local Health District. performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: I certify that in the employ any p persons subject to workman's compensa arson 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 cert_ify,that in the performance of the work for which this permit is issued,1 shall employ tion laws of California." The applicant sC f requ d ' spa tions. Comple awing on er side. Date: I Title: Signed FOR DEPARTMENT USE ONLY w Date Area f Applicatio Accepte by r�_B Date f" f y,� �✓3` Z) o Final Inspection by tion b ate �'�` uMfispe y f` 6 5q Z - r Additional Comments: C7 Stk 4&fi-6TB1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tr B3 6385 /Q a 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 9x201 CK RECEIVED BY PATE PERMIT N0. E FEE AMOUNT DUE AMOUNT REMITTED CASH INFO ts + EH 13-24 IREV.I/H 51 �� I EH 14-26 -