88-2939 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 R E CE I V ED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) NOV 21988 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her i e lrmn is made in compiance with San Joaquin County Ordinance No 549 for sewage or No. 1862 for well/pump and the RulVd�� Joaquin Local';Health'Distr3ct % + zMr:r _ k,T SERVICES !J�U r /fJ7 '��/ .+ .� If3-3SO Job Address-` City //?�f Size PM / �7 Owner's Name ..a(l��. uuflt elm (�� 6 Address • 12A I Phone S--633 L Contractor Address AVS /`-Y.jdl A_dC� License No. ,7Q�l l Phone TYPE OF WELL/PUMP: U NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �IR' i SEWER LINES DISPOSAL FLD. X60 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7Q-7r- Dia. of Well Casing Domestic/Private )4 Gravel Pack ❑ Tracy Type of Casing �I/'� Specifications f I Public F] Other C1 Delta Depth of Grout Seal Type of Gr it I I Irrigation I Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work bone Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') G TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION 1 I DESTRUCTION P I (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 soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS I I_ Depth Size _ Number SUMPS L� 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 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 applic nt just call for all requireq inspections. Complete drawing n reverse ide. q Signed X �t-� Ti I Date: IO 4o FOR DEPAR ENT USE ONLY Application Accepted by __ r Date r� Area Pit or Grout Inspection by Date 1�a Final Inspection by 'Date l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3f3621 ❑ Mante 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOU{NST DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH1324{REV.1/9,51 11 b a EH 14-2e l.J