88-693 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE„ STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED L (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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address I A fn dIn City sG616r Lot Size PM Owner's Name ..__.. !'�11 t"`S _._ Address C Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ NSTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL'D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA " CONSTRUCTION SPECIFICATIONS 0L "❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Cl Tracy —Type of Casing Specifications 4 1"Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 l Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by _ 1 f Repair"Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below ') TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIRlADDITION V, DESTRUCTION l I (No septic system permitted if public sewer is y t u 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: '. c z —Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments-- PKG. ompartments"' —PKG. TREATMENT.PLT. ❑;. � r Method of Disposal Distance to nearest: Welles Foundation- °Property Line '`sem tA IF LEACHING LINE [�No. & Length of lines l `"'""� o y i otal length/size r FILTER BED El Distance to nearest: Well LODE R Foundation v � Property Line 140 4 SEEPAGE PITS [ AT 11/Depth ___ _�Q ____ Size ��b Number SUMPS �f Distance to nearest: Weil FoundationI S 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. 4 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the;work'for Which this perfiI is issued, I shalt not employ any person in such manner as to become'sZiNict to workman's-cornpensation-law-s of-C�.alifdrnia-'Co'ntractor's hiring or S' -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- j tion laws of California." I The applicant must c III for ail uir inspections. Complete drawing on reverse side. ' i-- Signed X & Title: - LJ�P�'1 "I f Date: f FOR DEPARTMENT USE ONLY r Application Accepted by = }a Date 2 " ' Area Pit or Grout Inspection by Date Final Inspection to Date > Additional Comments: ' ❑ Stk 466-6781 R ❑/Lodi 369-3621 ElManteca 823-7104 C3Tracy 835-6385 cant Appii - Return all copies to: Environmental Health-Permit/Services,1601._E.,Ffazalton Ave,,,f.O._Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY' DATE PERMIT"NO. + EH13-24 1REV.I/H 57