88-2487 - Laserfiche WebLink

Home Browse Search

I - r . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED j (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 made in compliance with San Joaquin County Ordinarice No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 3, k /} kd JobAddress :- ��, � A iA // City sC,&l—Cot Size PM Owner's Name �. !fes„-1_�� Address tom' Phone C2 � � Contractor Address or License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F € FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom If Manteca Dia- of Well Excavation Dia. of Well Casing l I�Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L'1 Public 1-1Other ❑ DeltaDepth of Grout Seal Type of Grout I I i Irrigation - --Approx. Depth I I Eastern r Surface Seal Installed by Repair Work Done [ Type of Pump H.P l it State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I-1 REPAIR IAODITION l I DESTRUCTION l 1 Wo 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 ,-. p Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ .,Method of Disposal Distance'to nearest: Well Foundation Property.Line z LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑,,,_Distance to nearest: Well Foundation Property Line 1 l SEEPAGE PITS 1 1 Depth Size Number SUMPS ❑ Distance to nearest: Well` Foundation Property Line t DISPOSAL PONDS ❑ t 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. .4 t s 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 t6 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." t s-The-appl' mus call'for all required in ction ompl drawing on rse side. t SignedV Title: Date: OF W FOR DEPARTMENT USE ONLY t' Application'Accepted by Date Area ! l Pit or Grout Inspection by - " 17afe_ 7-Final Inspection by Date Additional Comments: LI Stk 46G-6781 -1 `O Lodi 369-3621 "r ;LI Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE t INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. + EH 13-24[RfV.1i85] EH 11-26