91-1254 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ) 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone 1209) 466-6781 MAY 2 3M (/ PERMIT EXPIRES TYEAR FROM DATE ISSUE ;l �v �N��. IRUNI�ENTA:� I�C�t�.TH (Complete in Triplicate) PERMIT/ SERVICES 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. 13 Job Address oC O 0 I1 C CityLot Size PM Owner's Name_ AIt� �� Address jC Phone ContractorPus>_kgoAddress License N0.91222_, �Phone 3 4?31131 9 ir TYPE OF WEL PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION M% SYSTEM REPAIR❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE 'I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ", ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth(of Grout Seal Type of Grout I Irrigation --Approx. Depth ( I Eastern Surface Seal Installed by Repair Work Done ElType of Pump _%2�.A_ H.P.'lYa_#AQ State Work Done 4 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material lBelow 501 r7� F TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION i l DESTRUCTION I I (No septic system permitted if public sewer is vV available within 200 feet.)- Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ; PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well ""Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation _-___. Property Line `ter t SEEPAGE PITS I 1 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS _.--Cl. u 1 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. F 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 applica t must c or all required inspections. Complete drawing on reverse side.. Signed Title: J € Date: E R DEPARTMENT USE ON Y int .ryQ / Application Accepted by �� Date V Area f Pit or Grout Inspection by Date Final Inspection by Date # Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8.23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IIlik— FFEO AMOUNT'DUE AMOUNT.REMITTED CASH CK RECEIVED BY DATE PERMIT NO. + EH 1 -24(REV,final EH 14"26 � � i i�-•