88-1071 - Laserfiche WebLink

Home Browse Search

1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I,Jo (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. Job Address /4Nx3 City Lot Size /6eoX !La" PM Owner's Mame P,�E Address Phone yty �4!� Contractor rL&�V J> c, Lc�r�ts;�_Address Pep A e?,y _ eP2- License No. EftA tF Phone 4v4_"3 7 TYPE OF WELLIPUMP: NEW WELL 171 WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR D 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 P� L Industrial Ei Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 15 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"I Public 1_1 Other P, Delta Depth of Grout Seal _ Type of Grout _ I I Irrigation __.Approx. Depth I I Eastern Surface Seal Installed by ---- Repair Work Done CI Type of Pump H.P. State Work Done Well Destruction 1 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTAL TION I I REPAIR/ADDITION l I DESTRUCTI N ANo septic system permitted i( public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other r 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 C\` Distance to nearest: Well Foundation Property Line r LEACHING LINE Ll No. & Length of lines _._ Total length/size FILTER BED I 1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth ------Size _ Number SUMPS I ? Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 17 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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: �1 Date: F SE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date f=inal Inspection by f Date Additional Comments: 'kk� ' '`'� '`� D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ` ❑ Tracy" 5-538 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. ox 2009, Stk., CA 95201 IN MOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT' y d2Y + EK 1324EH1 -2 (REV.ti:35; �'S ,0 __ VC �Q71