88-199 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT 3 O SAN JOAQUIN .LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA Telephone,(209) 466-6781 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 Local Health District. 6 Job Address City r�t Size PM +� I .Owner s Name r ss Phone Cantracto assa No. Phone W— TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL"FLD. PROP. LINE FOUNDATION "r 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �# f'l Public f7 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —..Approx. Depth _ I I Eastern Surface Seal Installed by _ c Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter w- c Sealing Material (top 501 Depth Filler Material {Below, TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONDESTRUCTION l I (No septic system permitted if public sewer is E > available within 200 feet.I -M». Installation will serve: Residence— Commercial_ Other Number of living units: f . Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 2 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ! Total length/size d ' FILTER BED ❑ Distance'to nearest: Well undation Property Line cr�19 i SEEPAGE PITS I I Depth Size iO u" umber SUMPS Ll Distance to nearest: Well oundation� 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. w 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, 1 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 f 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 app I' u f r ll retrdspections'Ca late drawing on se side. �, / n Signed X Title: Date: rFOR DEPARTMENT USE ONLY 1 t7 Application Accepted by iu Date d Y AAl rea 9 Pit or Grout Inspection by Date Final Inspection byDate 4 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.Q. Box 2009, Stk., CA 95201 x r' FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'Nd. + EH 13-241REV.r/H5) INFO. $76 '6� 6C e, CASH L^D ~U � � EH 94-28