88-53 - Laserfiche WebLink

Home Browse Search

:{ 1 APPLICATION FORPERMIT C� SAN JOAQUIN LOCAL HEALTH DISTRICT i V 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7'YEAR FROM DATE ISSUED (Complete in Triplicate) j 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 j 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. 1 Job Address -7,2&� &2 Ej - City lot Size M Owner's Name )� � Address Phone T Contractor /��if/�,�?l� 46�' ddress �.L_2}�A�• e4" e1icense No.4/9 1 _Phone,%'"'�� --TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ f DESTRUCTION-t❑. PUMP INSTALLATION, ". ! YJfM REPAIR ❑ OTHER' ❑ x DISTANCE TO NEAREST:`SEPTIC TANK SEWER LINES DISPOSAL FLD. 'PROP. LINE 1 ,�. FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS � I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t f Dia. of Well Casing 1i fl Domestic/Private ❑ Gravel Pack ❑ Tracy Tye of Casing ( Specifications a f'l Public ❑ Other C1 Delta f Depth of Grout Seal ^tel I Type of Grout ! I Irrigation —Approx. Depth I I Eastern f. Surface Seal Installed by Repair Work Done ❑ Type of Pump _ H.P. State Work Don d�U�t i ifs Well Destruction ❑ Well Diameter .` Sealing Material [top 501 .j Depth Filler Material (Below 501 1'_A—= V� TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial____ Other IC", �} Number of living units: Number of bedrooms } I' Character of soil to a depth of 3 feet: t Water table depth i SEPTIC TANK ' ❑ Type/Mfg Capacity____-i...__ IN Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation 4 Property Line LEACHING LINE . ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation .Property Line SEEPAGE PITS) L I Depth Size Number`L f I SUMPS $ Ll Distance to nearest: Well Foundation _-,Prfoperty Line DISPOSAL PONDS ❑ I hereby certify that I have.prepared this application and that the work will be done in accordance witli San Joaquin county ordinances, state laws, an 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 6f.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, 1,;il employ persons subject to workman's compensa- tion laws of California." r f f The.applicant must c for II requirgdtions. Complete drawing on raver a side. f ! :- - d t Signed X % � /��1 _ Title' : :'.Date ` + r s� FOR DEPARTMENT USE ONLY Application Accepted by v ___ Date1 'Areawy /� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _— El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' 3 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH G r ♦ EH 13-24(REV.I/M 5) EH 14-26 A�