88-2359 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ^- r Telephone (209) 466-6781 FRES 1 YEAR FROM DATE ISSUED V� PERMIT EXP C; (Complete in Triplicate) Co,-? ttSN Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described; T�Sfs1 �1ron is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for werpup and the Rules and �aquin m Local Health District. SER _ City Lot Size PM Job Address �J c. Owner's Name gal' Address Phone Cantractar a � Address L•g3.3 License No. 7-�'�g�Z'� Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Lr OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION 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 M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done X Type of Pump.� H.P. 3 State Work Done Well Destruction ❑ Well Diameter Sealing Material )tap 50') _ t c�z tet. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION 1 1 DESTRUCTION i I (No septic system permitted it public sewer is available within 206 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 IMfg 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 l I Depth Size Number SUMPS Ll 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. Phi Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work far 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 California." The applic all for all required,inspections. Complete drawing on r arse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �?�!� r �'- – Date �_,'L Area Pit or Grout Inspection by Data Final Inspection by _ Date./�l� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 L1 Manteca 823-7104 ❑ Tracy B35-6385 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 ASR RECEIVED BY DATE PERMIT NO. INFO q *.EH 13.24 IREV.+IH 5) EH 14-M