88-557 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES TYEAR FROM DATE ISSUED a (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 I Local Health District. Job Add ess '✓ ` City Lot Size PM Owner's Name Address -"� ' Phone V ContractorLic _ Q711ss ense No/,2"Phone r 7 TYPE OF WELLlPU P: NEW WEL ❑ WELL REPLACEMENT 9 DESTRUCTION 0r PUMP INSTALLATION IJ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FID. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' 4.1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t f ❑ Domestic/Private ❑ Gravel Pack L1 Tracy I Type of Casing Specifications (-1 Public 17 Other ❑ Delta Depth of Grout Seal Type of Grput _ 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 (Belo i TYPE OF SEPTIC WORK: NEW INSTALLATION 11. REF'AIR�ADDITIONIr DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ '-Type/Mfg li Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearestrtWell foundation Property Line LEACHING LINE f ❑ No. &'Length of lines 4 ° Total lengthlsize i TER BED ❑ Distance to nearest: Well _ Foundations Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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, I shall not employ any person in such-manner-as to become subiect-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, 1 shall employ persons subject to workman's compensa- tion_lawsf California." �* The applicant m tr equi;yttions. Complete wing on reverse side, Date: ✓` '`Signed Xi" Title: !r r FOR EPARTMENT USE ONLY / ~l � Area ' Appfication.Accepted-by _._ Date p Pit or trout Inspection by Date Final Inspectio/`n by Date 'Z� a ;Additional Comments: M4 V rA❑.Stk `466-6781 % ❑ Lodi '369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicants 119jurn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ��, f w _ FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. INFO s f13-24 IREV.tih 5f � '" EH 14-A �