88-2923 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT g 1601 E. HAZE T ON AVE., STOCKTON, CA y Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'i (Complete in Triplicate) oaquin Local Health District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San J 1 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 far well!pump and the Rules and Regulations of the San Joaquin Local Health District. sl1 0 City Lot Size !a PM Job Address e7 Q i3 Gr Phone Owner's Name r s I� se fVe. Phone 9 Contracto TYPE OF WELL/PU P: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PLl - SYSTEM REPAIR ❑ OTHER ❑ UMP INSTALLATION S FDISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial El open Bottom L3 Manteca Dia. of Well Excavation S ecifications ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing p rPublic fl.Other Ll Delta Depth of Grout Seal Type of Grout _ Approx. Depth I.I Eastern Surface Seal Installed by i I Irrigation — , Repair Work Done ❑ Type of Pump H.P. State Work Done _ s Well Destruction ❑ Well Diameter Sealing Material itop 50'1 �"`�/ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l i DESTRUCTION l 1 (No septic system permitted if public sewer`ls t available within 200 feet.) r Installation will serye: Res dence i Commercial f Other f � d Number of living units: T Number of bedrooms 2 Water table depth Character of soil to a depth of 3 feet: t' # SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ / Method of Dis osal �f 1 ,well ' Q2 Foundation -- Property Line Distance to nearest: ^t I I r A LEACHING LINE ❑ No. & Length of lines Total length size d FILTER BED Cl Distance to nearest: Well Foundation Property Line- s SEEPAGE PVT l I Depth Size Numbei ° P Distance to nearest: Well Foundation/ � — P SUMPS roperty Line , DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joagbinncounty ordinances, state laws,sand r 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 fhis 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 orsub-contracting signature certifies the fallowing:"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." l The applicant rpust c r all r quire -i s ctions. Complete wing on re side. Date: L1021 I Signed X f Title: } f FOR DEPARTMENT USE ONLY r Date " � Area 4 Application Accepted by J/ f Ii Pit or Grout inspection by Date Final Inspection by Date Additional.Comments: f ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE 'AMOUNT,DUE AMOUNT REMITTEDCASH RECEIVED l3Y DATE PERMIT NO. INFO A,4 { +.EH 13-24 EV.i/K,5) �� a.EH 14:26' •r