88-1899 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT '+ rTRWY 1601 E. HAZE I ON AVE., STOCKTON CA4 r (� Telephone (209) 466-6781 �3{lV__ ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) NSC A►- Application is hereby made to the San Joaquin Local Health District for apermit to construct and/or install the v1�'� ��C`� Plication is made in compliance with San Joaquin CountyOrdinance No.549 for sewage or No. 1862 for welllpump and the A s TT6` aalhk o the San Joaquin Local Health District. f Job Address l7l r'l-� City Lot Size PM Owner's Name /�t � "e Address /°r 1 •11 � L- Phone Contractor 4-"dress a 4 ic'ense No. L)1 Phone l TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 11LI21.2SEWER LINES DISPOSAL FLD. PROP. LINE \ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Od Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 117{ Gravel Pack ❑ Tracy Type of Casing 'S np 4 Specifications ('1 Public L1 Other ❑ Delta Depth of Grout Seal Type of Grout )d Irrigation �_ Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter _ Sealing Material [top 501 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION l I (No septic system permitted if public sewer is 0 • available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line (L� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well ___--.— Foundation Property Line SEEPAGE PITS I I Depth Size ___.—_ _ Number SUMPS L1 Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS Cl 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 Com' 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- nom+ tion laws of California." ,v The applicant ust call far all requ' d inspections Complete drawing on r v sdsi . Signed X Title: Date: FOR DEPA TMENT USE ONLY Application Accepted by Date —0�7- Area Pit or Grout Inspection by Data Final Inspection by zl 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE fiPRMIT Np.INFO CASHEH I -24IFIEV.IiM51 { ^�"'�"�� EH 14-28 ' C/