88-1528 (2) - Laserfiche WebLink

Home Browse Search

A?PLI.CATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N� ^ `'L A� 1 1 (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. r f Job Address City �/ d of Sizea PM f � r wner's Namee Address �'� � �� Phone 4_7L Contractor Address License No. Phone TY E OF WELL/PUMP: NEW WELL WELL REPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM R PAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU URE W L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial L1 Open Bottom ❑ Manteca Dia. Well Excavation Dia. of Well Casing ❑ Domestic/Private Ll Gravel Pack ❑ Tracy Type of ing Specifications (1 Public Cl Other fl Delta Depth of Grou eel Type of Grout I I trrigation --Approx. Depth I i East n Surface Seal Install by `l Repair Work Done ❑ Type of Pump H.P. S Work Done_ T Well Destruction ❑ Welt Diameter Sealing Material (top 50') Depth Filler Material (Below 501 \� TYPE OF SEPTIC WORK: NEW INSTALLATION l EPAIR/ADDITION 1 1` DESTRUCTIO (No septic system permitted if public sewer is -available within 200 feet.) Installation will serve: Residence_ CA. ommercial— Other Number of living units: -2— Number of bedrooms 4 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 LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 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. 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 taws of California." The applicant mus call for all required inspections. Complete drawing on reverse side. Signed;,,gTitle: ,/7 (LIL _ Date: - `Y, bb F DEPARTMENT USE ONLY Application Accepted by �Q.C��t,� `� Date b� �G�� Area '�t or Grout Inspection by DateFinal Inspection b Date------ *ional Comments: _ Y 9 ^ � 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 Tracy 835-6385 t Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IN MOUNT DUE AMOUNT REMITTED CASH CK RECEIVED By DATE PERMIT'NO. s . A s � c L4 6A 19