88-807 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T'YEAR FROM DATE ISSUED (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 Health District. Job Address c;Wc- ,&,�e - — City Lot Size PM Owner's Name Address �t` Phone Contractor Address r1c�i1---, 19'jl C�� hv License No. Phone TYPE OF WELL/PUMP: NEW WELL,El WELL REPLACEMENT ❑ DESTRUCTION ❑ - " PUMP INSTALLATION DiWxpekokiv7§YSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 A Domestic/Private ❑ Grave( Pack E2Tracy Type of Casing Specifications 1' Public ❑ Other C-1 Delta Depth of Grout Seal Type of Grout . I I Irrigation —,.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done" ❑ Type of Pump_ H.P. f State of rk Done 1,Q BA,A:f Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth /-Piller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR IADDITION_l ) DESTRUCTION I--]-1Nii septit—sys(em permitted if public sewer is ! available within 200 feet.) Installation will serve: Residence Commercial- Other Number of living units:_ Number of bedrooms t-Character of-soil to a depth of 3 feet: F Water table depth SEPTIC TANK Cl 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 `�❑r Distance to nearest: Well Foundation Property Line f SEEPAGE PITS ;d i I Depth Size Number ti t A SUMPS a ❑ Distance to nearest: Well Foundation Property Line ,y , DISPOSAL 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 shalt 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 applicant f all req i 4pections. Complete drawing on revers side. c� , Signed X Title: � '� �L Date: FOR DEPARTMENT USE ONLY Application Accepted by 19Date " V Area [(3 60 Pit or Grout Inspection by Date 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 95201 FEE INFO fAMOUNT/pUE AMOUNT REMITTED ASH RECEIVED BY PATE SPn(ERMIT"xnNO. + EH t3-244REV.r/Nsl G�NCJ EH 14-28 - tl