88-2742 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA j Telephone (209) 466-6781 I11 (5 '�9 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V E (Complete in Triplicate) OCT., 12 10,88 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 Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Hegulatiop�Qf, hj quin Local Health District. LNNrv'li� NN!T1 IML f ERWT f S�EWCES Job Address /O G City I rLot Size PM Owner's Name ,G/ ddress 0 �- Phone Ik .. x Contractor �&"Cx Address icense 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 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 0?'l5&mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 1-1 Other - CI Delta Depth of Grout Seal Type of Grout `-I I Irrigation _..Approx. Dept__11 11 Eastern Lu Seal Installed by - Repair Work Done ❑ Type of Pump - �h - H.P. State Work Done Well Destruction ❑ Well Diameter 4! Sealing Material {top 50') Q Depth Filler Material (Below 601 I TYPE"OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIAODITION I I DESTRUCTION I 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 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER'BED ❑ Distance to nearest: Well Foundation Property'Line SEEPAGE PITS I I Depth 'Size s _ Number SUMPS 0" Distance to nearest: Well t 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 Di$trict.t 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 taws 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 # The applicant mus II for all requ' d ctions. Complei drawing on reverse side. Sign X Title: a Date: Q �d FOR DEPARTMENT USE ONLY 71 Application Accepted by Pin Date ✓ Area ' Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 } Applicant • Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 20M, Stk., CA 55201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH I +.EH13-24fREV. sl b/+� EH 14-28 �� -�� r