88-2766 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT Ili$ 41P SAN JOAQUIN LOCAL. HEALTH DISTRICT �''°� Q° OAYM'ENT 1601 E. HAZELTON AVE., STgCKTON, CAp�wt`�REGEiVED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PgW OCT 131988 (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein�TE ENVIRONMENTAL HE&tion 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 istrict.Job Address 6 ! �/'0 ©/''fS Z n, e City Lot Size PM POwner's Name �" p2 S-S / 6e- one C, r4 I�� Address L ms Phone 6 .3 3o-2- Contractor + e� Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP 1fJSTALLATf01�`❑ SYSTEM REPAIRµ/] - YOTFiER ❑" -_�== "' - ='S DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing O Domestic/Private 171Gravel Pack ❑ Tracy Type of Casing Specifications i'l Public ❑ Other y Cl Delta Depth of Grout Seal Type of Grout _ I'I Irrigation --Approxi Depth l I Eastern Surface Seal Installed by Q� i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION l I DESTRUCTION I. 1 (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve:, Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soi to epth of 3 feet: Water table depth SEPTIC TANK ❑ /Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ell Foundation Property Line a LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED E) Distance to nearest: ' Well Foundation Property Line k SEEPAGE PITS I I Depth Size_ a "^ `-`x-� � _ — Num t�er: SUMPS Ll Distance to nearest: Well Foundation Property Line 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. 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 f employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 must 11 for all required inspecti s. Complete drawing on reverse side. Signed X Title: Date: ( 0 -- (2- - 5T f s R Dp ENT USE ONLY Application Accepted by _ Date v 72 �'-4 rea ©� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i ( Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI7'NO. ♦.Eti14-24(REV.1iH5) � EH t4-2B �` 1 1 g-�7