88-2912 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT " 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone f209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicaon is herebyt to constru all the work . This cation is ' made inti rcompliance writh SanoJoaqu nthe SanCounty OrdinaJoaquin nce No.549 for sewage orealth District for a 'No. 1862 for well//pump atnd the Rules and IR Regulations of he San l Joaquin f Local Health District. ' 'I f Job Addressj?SZ / i k[1�� CityS�� Lot Size PM 'I I Owner's Name Address 1.�1L Phone a �t� 03 � 9 A. ! Contractor^Lr� � Address OaLl License N �Z.Zz- Phone_ TYPE OF WELL/PUMP: NEW WELL 171WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS "I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing aSpecifications ❑ DomesticIPrivate ❑ Gravel Pack ❑ Tracy Type of Casing i`l Public ❑ Other F1Delta Depth of Grout Seal Type of Grout I i Irrigation- _Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done [IType of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material'(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION t 1 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installationwill serve:, Residence— Commercial_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UTotal length/size ❑ No. & Length of lines g i FILTER BED ❑ Distance to nearest: Well Foundation Property Line � II SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ 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 Diltrict. 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 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 t must call for a1 required ' tions. Complete drawing air Signed X� Title: Date: 6 FOR PARTMENT USE ONLY ( � Application Accepted by Date �' V �f Area Pit or Grout Inspection by Date Final Inspection by e"- Data 'A Additional Comments: ElStk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 . ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 A k " h FEE ArMOUNT DUE AMOUNT REMITTED K R RECEIVED BY DATE PERMIT'NO. INFO 9CM{c� 2 G O ^7 EH 13-24(pEV.r/N 5) `�t(5-J �,3�-_ EH 14-28 V - "