88-452 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT _ SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601.E. HAZEL i ON'AVE., STOCKTON, CA _ Telephone(209) 466-6781 PERMIT EXPIRES'1 YEAR FROMDATEISSUED (Complete in Triplicate) I Application is hereby made tothe San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is 1 made in compliance with San'Jaaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulatioris of the San Joaquin { Local Health District. s !' S r PM ; ' Job Address r City Lot Size i I� Owner's Nam Address Phon� ontracto � (GTS F Addres + ' ense No. PhOn Cr TYPE OF WELL/PUMP: �I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ $ t r PUMP INSTALLATION C1i SYSTEM REPAIR ❑ OTHER ❑ ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE ��TYPE OF WELL r PROBLEM AREA CONSTRUCTION SPECIFICATIONS �..r ~ 171 Industrial ; i] Open Bottom ❑ Manteca Dia. of Well Excavation ; Dia. of Well Casing T of Casing Specifications D Domestic/Private � Gravel Pack � � ❑Tracy YID 9 LJ Public , Ul Other r ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation I k LI--Approx. Depth ❑ Eastern Surface Seal Installed by p. i Repair Work Done ❑ Type of Pump H.R. State Work Done 9 4 is Well Destruction ❑ Well Diameter Sealing Material Itop 501 I Ai 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: ;NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is el, I , available within 200'feet.) "! I I Installation will serve: Residence_ commercial_ Other } Number of living units: L Number of bedrooms 3 .r Character of soil to a depth of 3 feet: Water table depth c� SEPTIC TANK D Type/Mfg R a Capacity No. Compartments., l' . ..,-." . . �.. i PKG. TREATMENT PLT. El of Disposal Distance to nearest: Well Foundation Property Line ., r ,}a ,TL i length/size 'LEACHING LINE No. & Length of lines Notal !en g FILTER BEDfi ❑ Distance to nearest: Well Foundation - Property Ling SEEPAGE PITS Depth .-Size R Numbe �I +t / SUMPS X Distance to nearest: y`WeII V-Foundation Property Line DISPOSAL PONDS ❑ a A 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.K ra. Home owner or licensed agent's signature certifies the following:_I certify::that in the.,perfommance of the work for which this permit is issued, I�shall not ti 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. R ." £ ►, ` ' ; i I The applicant must call forall req 'e ,ins tions„ Cor9gete drawing on reverse side." Signed Title��" ` Pate: g FOR DEPARTMENT USE ONLY f a rea Datr- C.� U AF I i Application Acc�Qted by � � ► a � a :,� �! !C r i Pit or Grout Inspection by� Date f Final Inspection by. Data : ; Additional Comments: Sk' ft C1Stk 466-6781 ❑i Lodi - -3621. ❑ Manteca 823-7104 ❑ Tracy 8354385 s 1° Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201' # FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT`NO. 1 INFO 1 s + EH 1324(REV.I/e 6l EH 1428 1, i a L _ _._