88-610 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—ION AVE., STOCKTON, CA Telephone 12091 466-6781 'PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) application is e No. 549 for sewage or No- 1862 for well/pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described-This App Ordinance ' made in compliance with San Joaquin County Local Health District. , PM �- Cloy Lot Size�, k Job Address lLI a` Phone ! �] Address 4 _ l L�(.t 4 Owner's Name ��(�.. 3 � t License No. � Phone ' Address DESTRUCTION ❑ Contractor- WELL REPLACEMENT ❑ 1 i NEW WELL ❑. OTHER ❑ r TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ / PUMP INSTALLATION ❑ DISPOSAL FLD- - PROP. LINE SEWER LINES —� �' --. -�,�.�^. - DISTANCE TO NEAREST: SEPTIC TANK -� _ __ - -PlT57SLf1VIP5 FOUNDATION AGRICULTURE WELL OTHER.WELL-r--- INTENDED USE TYPE OF WELL PROBLEM �.CONSTRUC710N SPECIFICATIONS Dia. of Well Gasin0— (n1 T;^C] Open Bottom-.. Dia. of Well Excavation" Specifications v Mp-Manteca�,,;,.�. .- �. ( __❑ Industrial ❑ Tracy Type of Casing _ 1 - ❑ Gravel Pack Type of Grout ❑ DomesticlPrivate [=1 Other CZ Delta Depth of Grout Seal [-I Public - Surface Seal Installed by i ` I 1 Irrigation `"Approx. Depth [ I Eastern State Work Done Type of Pump �- H.P. Repair Work Done L] Typ _ ti Sealing Mater[a[ I"top 50'1 Well Destruction D Well Diameter -- Material (Below 50') r Depth DESTRUCTION.I 11 [No septic system permitted if public sewer is TYPE OF SEPTIC'WORK: NEW INSTALLATION I l EPAIft!r DDITID �' available within 200 feet.I Commercial Other — f ❑ ial '�� � j Installation will serve: Residence r f � Number of rooms Water table depth Number of living units: _L-- i Character of soil to a depth of 3 feet: ;.:., No. Compartments Capacity- ��, - SEPTIC TANK ❑ Type/Mfg " _ _ _-. i `' I Method of Disposal J� 1 PKG. TREATMENT PLT- ❑ Property Line_��-i s ;� J,:V- Distance to nearest: We1F;�� Foundation w Total length/size LEACHING LINE _❑ No. & Length of lines �� Propert Une� .+oundation FILTER SED El Distance to nearest: Well / r f e , �-Side� `� �; Number I SEEPAGE PITS Depth 11 Property Line__�--- '"` C31� -Foundation�.—� SUMPS L� Distance to nearest- Well ' f DISPOSAL PONDS ❑ - f { hereby certify thad, I shall not t' have�pre aced this application and that the work will be done in accordance with San Joaquip,county ordinances, state laws, an ` rules and`r'sgulations of the San Joaquin Local Health District.g � F Home owner or licensed agent's signature became subject lto wrorkman'srtcompansation IaewsoomCaliforrn a." Contractor's which hiring r orr sub-contracting s permit is signature employ any person in such manner persons Subject to workman's compensa- certifies the following: "I.certify that in the performance of the work for which this permit is issued, I shall employ f tion laws of California." The applican ust call f all quired inspections. Complete drawing on reverse s[p. Date: Title: Signed X FOR DEPARTMENT USE ONLY Area / — Application Accepted b Date Y -In Pp �° k Date,�.�� Final lnspection.by , l �or Grout Inspection by L Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369-3621 Stk., CA 95201 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, CK RECEIVED BY ' DATE PERMIT-NO. FEE AMOUNT DUE AMOUNT REMITTED CASH //0 INFO �(I/�1 Q� r/'t + EH 13-24 4REV.t/H 51 X i 11 lJ 61 3 EH 14-26