88-244 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -7 7Z (Complete in Triplicate) F4�VfR0�fi.";TAL HEALTH rr .rr /��r>ri Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hettia.?(ascribed-fhi5`SNcation 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. Job Address Q d f City Lot Size PM Owner's Name LL I a Address j 0 t Phone Fd —S�fl 2— Address License No./4 % Phane746� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR Q ' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ❑ Industrial ❑ Domestic/ Private F1 Public I I Irrigation Repair Work Done FJ Well Destruction ❑ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Gravel Pack ❑ Tracy Type of Casing Specifications Ll Other F] Delta Depth of Grout Seal Type of Grout . _Approx. Depth ! I Eastern Surface Seal Installed by - p r Type of Pump H.P. 1 State Work Done Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Other Water table depth _ Capacity No. Compartments Distance to nearest: Well Foundation LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Method of Disposal Property Line Total length/size_ Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line nISPDSAL 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: "1 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 California." The applicant st II for all re fired t* ns. Complete� drawing on reverse side.. Signed X l+tle: Date:! 44 FOR DEPARTMENT USE ONLY Application Accepted by Date Area 0 44 Pit or Grout Inspection by Date 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, Sik., CA 95201 r EH 13-24 (REV, 1 / H 51 EH 14-26 FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT -NO. INFOds