88-1549 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,SUN 3 1988 (Complete in Triplicate) *�,,ll pp EALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the v R� 9 �J plication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Aul@s�I{t4 an Joaquin Local Health District. Job Address Lfm a1 i /l�tP1y� City Lot Size PM Owner's Name//l L/d. Address Phone Contractou �i Address1A� �clJr-�C _ License No 52,} Phone929-4`206 (\, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER k, Q -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP.-LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM-AREA .:..CONSTRUCTION.SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I)L Domestic/Private ❑ Gravel Pack ❑ Tracy Typefof Casing Specifications 1 1-1 Public F Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done of Type of Pump.Qe1d4.1 H.P. State Work Done. Weil Destruction ❑ Well Diameter Sealing Material Ito p 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION,( 1 DESTRUCTION l I INo 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 soil to a depot of 3 feet: f Water table depth SEPTIC TANK ❑ Type/Mfg + I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well~N Foundation Property.Line LEACHING LINE ❑ No. & Length of.lines` t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i r SEEPAGE PITS I I Depth Size _ Number 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 he 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 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." The applicant must calk r all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOWDEPARTMENT USE ONLY i Application Accepted byDate Area—Oil Pit or Grout Inspection by Date Final Inspection by Date 1 Additional Comments: ❑ Stk 466-fi781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Appiicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT'NO.- +.EH 13-24(RE EH 14-26