88-1270 - Laserfiche WebLink

Home Browse Search

q 2, lio APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` r> (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 Healih District. Ir JobAddressk h-/ City Lot Size PM Owner's Name dress r 4, ` 1 " ` -Phone Contractor ress nse No Phone TYPE OF WELL/PU P: NEW WELL ❑, WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR-❑ Y OTHER O r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F f _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private- ❑ Gravel Pack ❑ Tracy Type of Casing Specifications � 1'1 Public 1-1 Other ❑ Delta Depth of Grout Seal _ Type of Grout I I Irrigation —.-Approx. Depth wl I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ID Well Diameter Sealing Material /top 1 Depth E Filler-Malaria IBeI9W TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence= Commercial Other " Number of living units: A_m Number of bedrooms t s r , Character of soil to a depth of 3 feet: Water table depot SEPTIC TANK- ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ s Method of (ljsposal P i Distance to nearest: Well Foundation Property Line �. LEACHING LINE?f" ❑ No. & Length of lines Total length/size FILTER BED T',4A q ❑ Distance to nearest: Well Foundation Property Lirie f ref: , SEEPAGE PITS I 1 Depth '; 4 Y r /" _ Number F 'SUMP L-I Distance to nearest: 4nll Foundatior r- Property Line ' Di�NOSAL 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. 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 compansa- tion laws of California." i f k The applicant must call f r all require s ctions. Complete awing onn se side. Signed X Title: _/ ' Date: _ FOR DEPARTMENT USE ONLY ` Application Accepted by ' Dates '' � Area Pit or Grout Inspection by-7- Date_ Final Inspection by Dateof _ dl A I Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ racy 835-6385 n r--T.3, Applicant.-,Return all copies to: Environmental Health Permit/Services 1601..E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i e INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE "PERIMIT'NO. EH 13-2t/REV.i i H51 ; EH 1�-28 T---�