88-1095 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT ; a 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (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 Sari 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] Job Address / City. of Size 7Sk��3 5 PM 1 Owner's Name PhonelI� `� �? r�-// Q c"^"Rd r8 ess�/ Phone w �� U / v Contraotor License No. Phone_ Address �`f t TYPE OF WELLIPUM : NEW WELL ❑ WELL REPLA NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYS M REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC NK .SEWER LINE DISPOSAL FLD. PROP. LINE FOUNDATI AGRICU RE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL- PROBLEM EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom an ca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Gravel Pack ❑ a Type of Casing Specifications {7 Public (7 Other Delta Depth of Grout Seal Type of Grout f I I Irrigation _.-Approx. Dep I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ K Well Destruction ❑ Well 0'1 Diame r Seating Material It 5 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [1 HFPAIR/ADDITION i I DESTRUCTION (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 F SEPTIC TANK ❑ Type/Mfg 4 Capacity No. Compartments PKG. TREATMENT PLT. ❑ t:T. Method of Disposal Distance to nearest: Well Foundation Property Line s LEACHING LINE ❑. No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' 'Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 7 SUMPS L� Distance to nearest:' Well Foundation Property Line DISPOSAL PONDS I❑ 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 i 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 I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed Title Date-,Date-, �� ' a=ZeFOR DEPARTMENT USE ONLY Application Accepted by _ Date -5/43 � Area Pit or Grout Inspection by ate 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 2009, Stk.,.CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED C K# RECEIVED 8Y DATE PERMIT*IVO. INFO r.EH 13-24 MEV.t/N 51 �� EH 14-2e I