88-386 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11,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 Sad-Joaquin Local Health District. s Job Address City Lot Size _ PM MCI, Owner's Na Address �� _/ •�: /Std Phone 7 J Y f Contractor Address G License No Phon TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT El 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 ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ['1 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 ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commerka — Other Number of living units: Number of bearporhs, �7©1 Character of soil to a depth of 3 feet: Water table depth v SEPTIC TANK ja/Type/Mfg O Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal / Distance to nearest: Well Foundation�_ Property Line LEACHING LINE C4i'No. & Length of-fines-? Total length/size J A0 El ' `/, _ FILTER BED. Distance to nearest: Well Foundation 40 Property Line SDO SEEPAGE PITS 14-Depth Size �Number SUMPS P Distance to nearest: Well a Foundation �Q 5�— Property Line �— DISPOSAL PONDS ❑ = r 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, 1 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 must call for aji required inspections. Complete drawing on verse side. Signed X Title: 04-J 2A Date: a FOR.OEP-A&T&4ENT_USE ONLY_ rN Application Accepted by1 Date Gam-- Area Pit r Grout Inspection by ate!�4-15_ ' e Final Inspection by Dat i 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, Stk., CA 95201 01 y/vusc, FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE MIT NO. INFO CASH + EH 13-24(REV.1 i x 5) lot60 ��G ' � ' oPER EH 14-28