88-2731 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT .. n t_I _ SAN JOAC2UIN LOCAL-HEALTH DISTRICT 1601 E. I-iAZELTgN AVE., STOCKT0N, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 COUK Ordi ante No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District- tp h � RT Job Address �L 11�P � / �` ` City J rL�C Lot Size PM / w l cnGLJ-f ! r r ��y Address —3"`Y7 C zy i 46 ko C-1 L. Owner's Name f w-r� / Phone �f�p Contractor 0 ��' Dr'L�r(h% ddressyy A: 4l bl�/ License No. L0Z Phone TYPE OF WELL/PUMP.: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK &'0? SEWE=R LINES DISPOSAL FLO. A"',f PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL -e PITS/SUMPS _ INTENDED USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQ US I LI Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing j *)(Domestic/Private ravel Pack Tracy Type of Casing / Specificationsl a - i F] Public / Cl Other F] Delta Depth of Grout Seal Type of GroutPr9 9_tA� i 1-1 Irrigation pprox. Depth I ] Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50') 1 Depth Filler Material lBelow 50') ] TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (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 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 j SUMPS Cl Distance to nearest: Well Foundation Property Line [ DISPOSAL PONDS ❑ 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 Californ' The applicant st all for all eq re inspections. Complete drawingon rev rse side. Signed X Title: _,Alell Date: /R-y FOR DEPARTMENT USE ONLY {+ c Application Accepted by _ date 1P—t 13 Area - t Pit or Grout Inspection by Dater Final Inspection by Date 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 95201FEE ` INFO AMOUNT DUE AMOUNT REMITTED LK 4 CASH RECEIVED BY DATE PERMIT'NO.EH 13-24 j + EH 14-26 iFEV.i/H51