88-2127 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. J � City Lot Size PM Job Address, 1 Owner's Name Address �.7d� J!. ' 1`� Phone Contractor E Address License No. ' Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ i FUMP�I�NSTALLATION C1 - SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES ,DISP_OSAL-FLD. PROP. LINE '-.FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 07Qpen Bottom ❑ Manteca Dia. of Well,Excavation Dia. of Well Casing -ti Specifications Pack ❑'Domestic/Private C7`Gravel Pack ' D Tracy Type of Casing f Public (l O her t n Delta Depth of Grout Seal Type of Grout -. I I Irrigation. K _g..Approx. Depth 1.1 Eastorn Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P M State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 { Depth Filler Material (Below 50'l TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION i ]_(No septi'c system permitted it public sewer is v _ _ available within 200 feet.) Installation will selves- Residence� Commercial Other Number of living units: =' Number of bedr oms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, GD Method of Disposal Distance to nearest: Wel! Foundation Property Line r � I LEACHING LINE .❑ No. & Length of lines r Total length/size t. "FILTER BED lD Distance to nearest: Well Foundation Property Line SEEPAGE PITS {'l Depth Size um r SUMPS L-1 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 Di§trict. 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 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 Califo ia." The applicant m st I r all required i ct' ns.,C t Ing on reverse side. c� Signed X ills: Date: Dg F R DEP TMENT USE ONLY' - r� Application Accepted by DateArea- . Pit or Grout Inspection by A Date r, Final Inspection by Date7SL Additional Comments: U-� � �� ` i 11 Stk 466-6781 EI Lodi 369-362 ❑ Manteca 82:f7104, El Tracy 6385 0� 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 By DATE PERMIT'NO. INFO i4t //EH 13-24(REV.t i n 51 �'� / r f EH-14-2a