90-1871 - Laserfiche WebLink

Home Browse Search

A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT WGGL— 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ;N (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 p 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 Address 2y wa City .Slt ?Orf'i Lot Size PM ----..--.Owner-s-Name-- • V-kM --GACLA1114J4�bdcess�._ Y -P-hone- - 5 Contractor 7L "OSS c&_Sym-5 Address 71 License No.�'3a!9/C Phone 7 -22 TYPE TYPE OF WELL/PUMP: NEW WELL P_' `WELL REPLACEMENT ❑ DESTRUCTION ❑" 'i E,.= '} ►Y- h . PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �Gt�� SEWER LINES DISPOSAL FLD. PROP. LINED FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTtENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 2.. D Industrial Vopen Bottom El Manteca Dia. of Well Excavation k Dia. of Well Casing LJ Domestic/Private ❑ Gravel-Pack-71 Tracy ;ie, Type of Casing sreie( i Specifications 11 71 Public Cl Other Cl Delta Depth of Grout Seal f-, Type of Grout 95GtC� f ItkIrrigation 0..Approx.Depth ( I Eastern , Surface Seal Installed by XMo, iV { Repair Work Done L7 Type of Pump H.P. - State,Work'Done Well Destruction ❑ Well Diameter Sealing_Material'Itop-5¢_i__ �� J Depth Filler Matete-,IlBelow_5q'1� _ --• - M TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i"I DESTRUCTI13N•l I INo septic system permitted if'public sewer is �} 4 available within 200 feet.) 1� Installation will serve: Resi ence_ Commercial_ Other Number of living units: u bedrooms ='2" 1 � Character of soil to a depth of 3 feet: ' f'. Wa a depth SEPTIC TANK ❑ Type/Mfg Capacity .No. Compartments 1 PKG. TREATMENT PLT. ❑ J Method of Disposal Distance to nearest: Well } Fou ' n Pro ine 1 LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to near Well Foundation Property Line it w3 'A SEEPAGE PITS l Ith Size Number SUMPS ® Distance to nearest: Well Foundation Property Line I� DISPOSAL ISPOSA DS ❑ I t I 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 DFstrict, 1i I 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." ;k l The applicant must call for all required inspections. Complete drawing on reverse side. I E k +" Signed X .to7'L- Title: joda Date: FO EPARTMENT USE ONLY t - Application Accepted by Date aQ Area 1 Pit or Grout Inspection by Date Final Inspection by _ s Date i 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"No. +.EH 13-24 EH10.2BIAEV.iin51 `�'� QC� 0 3037 D � itJJ