88-734 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67811 • r PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (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 Ordinance No. 549 for sewage or No. 1862 for well/pump,and the Rules and Regulations of the San Joaquin i Local Health District. i �Z+ GFt ��r City �t 1 I�ot Size PM Job Address a i� ��- � ' 4 Owner's Name �r � l I i6. Address l Pone Contractor Address _ e No: Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL CEMENTr DESTRUCTION ❑ }} \ k PUMP INSTALLATION ❑ SYSTEM REPAIRCd'Afl,, fit X t {? ��-' �� OTHER RC1 i lr`l F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALINF,Lq,t, �T PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 'I�TYPE OF WELL PROSLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial b Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing tt -L-1 Domestic/Private ❑ Gravel Pack f ❑ Tracy - Type of Casin g� ��f Specifications CwtY�7� CZ I-) Public GI Other 171Delta Depth of Grout Seal ^' Type of Grout I i Irrigation h _A'pprox. Depth I I Eastern Surface Seal Installed by Repair Work Done n Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter _ Sealing Material Itop 50') Ong ra t'tvi 0,-1� Depth ^-' Cos 701 Filler Material (Below 50') TYPE SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION ! I (No septic system permitted if public sewer is 11. 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 FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS I I . Depth Size Number SUMPS L1 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 rnia." The appl' nt st cal for requir inspections. �rat.O,nq �? Signed y� Title: �J Date: Q� 1 FOR DEPART USE ONLY r Application Accepted by IE Date r Area Il Pit or Grout Inspection by ` Date f Final Inspection by Date �� ' Additional Comments: ! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant -t{,Return all copies _to:�1Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4iij l I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO 1/-7/ EH 13-24 1REV.t i N 5l o`--� EH 14-26 b / '""`"7777JJJJ ��////