88-783 - Laserfiche WebLink

Home Browse Search

3. APPLICATION FOR PERMIT T ". . i k- _. SAN JOAQUIN,LOCAL HEALTH DISTRICT 3 1601 E. HAZELTON AVE.,-STOCKTON, CA Telephone (209) 466-6781 +c PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED �`.JJ .. . (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 describ^ed. 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. Job Address I c r(J.uw I~ City a a- tot Size PM Owner's Name Q Address a 7�u..�. 4 � -�•�� _ Phone Contractor Address ASO A , .Z;:C License No.3T?6S/_0 Phone TYPE OF WELL/PUMP: �JNEW WELL I& WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER'❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.i PROP..LINE 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 L� ❑ Domestic/Private s ❑ Gravel Pack ❑ Tracy Type of Casing Specifications E-1PublicO Other © Delta Depth of Grout Seal Type of Grout IQ Irrigation s --Approx. Deth ElEastern Surface Seal Installed by - Repair Work Done A.—Type of-Pump H.P.'A5,_ State,Work Done -�--� i Well Destruction F-1WellDiameter Sealing Material (top 50') Depth Filler Material /Below 501 JD TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ` available within 200 feet.) Installation-will serve: Residence Commercial_ Other �f 1 Number of living units: ti Number of bedrooms Character of soil to a depth of-3 feeti- Water table depth SEPTIC TANK ❑ T e/Mf �_ YP 9•- `'_•r Capacity No. Compartments PKG. TREATMENT PLT. ❑ �_* h ;F Method of Disposal Distance to nearest: Well Foundation 4Property Line x LEACHING LINE ^j ❑ No. & Length of lines '`� P `* Total iength/size FILTER BED f ❑ Distance to nearest: v Well Foundation � '`Property Line SEEPAGE PITS' I ❑ Depth Size rN Number - SUMPS i El - Distance to nearest:- Well Foundation—. _, - !Property Line' DISPOSAL PONDS ❑ c I I hereby certify that'l 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 fallowing: "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: '9 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 ap t call for all req ins Ions. omplete drawing on 'reverse side. r>. Signed X Title: LE'*PJ Date: Imo: _.•\. "'� ,. .p. _ FOR DEPARTMENT-USE ONLY ? A lication•Acte ted b r 4 U PP P Y Date -=' Area Pit or Grout Inspection by Date Final Inspection by Date a ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0.Manteca -7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Service's 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PpERMiT NO. + EH13.24-(REV.1/115) - - - _ ¢S 9-3 . EH 14-28 r� t ` --'"7