88-778 - Laserfiche WebLink

Home Browse Search

,^. A, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.,STOCKTON, CA " Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a � t0Q, s (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 Irre City �J�CJ apt Size PM Owner's Name a Vc7L. ^ -- 7�S- Address Phone �d ContractorJ9111 -LaAddress License No,32 QS60— Phone TYPE OF WELL/PUMP: 1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION 11SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ' FOUNDATION AGRICULTURE WELL' , e £;OTHER WELL PITS/SUMPS INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial I ' ❑ Open Bottom F Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private' ❑ Gravel Pack ❑ Tracy Type of Casing ' t Specifications ElPublic ❑ Other ` ❑ Delta Depth of Grout Seal Type of Grout E) Irrigation i+ _.__Approx. Depth LJ Eastern Surface Seal Installed by Repair Work Done '❑ Type of Pump H.P. te-Work Done, oil Well Destruction � Well Diameter Sealing Material Itop 50'1 1. ' Depth rL. f Filler Material (Below 50') go a �• TYPE OF SEPTIC WORK: NEW INSTALLATION � EJ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if publicwe ser isx - installation k.will serve: Residence Commercial— Other, available within 200 feet.) Number of living units: Number of bedrooms Y Character ofsoil to a depth of 3 feet: Water table depth � r SEPTIC TANK I ❑ Type/Mfg Capacity No. Compartments PKG- TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well Foundation s ! I Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C] Distance to nearest: Well Foundation I" l ° Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 171 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 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." Ry The appl-Ica ust all for all require _i pections :ompl a drawing.o reverse side. v Signed X — Title: 12 C2 f 1 �' _.Dater - `` FOR DEPARTMENT USE ONLY Application Accepted by - (� Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 "13 Lodi 369.3621 © Mantace,,823-7104 El Tracy 835-638,5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hiie#on Ave.,\'PiO Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK - INFO CASH RECEIVED BY DATE PERMIT�NO. + EH 13-241REV.I/AS) ' K� - EH 14-28 c.J ^^ k