001545 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT M f JOAQUIN LOCAL HEALTH DISTRICT �(� X 160 E HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 L'nocaa'Health ° Il�I EXPIRES TYEAR FROM DATE ISSUED(Complete in Triplicate) gLehy..made-•t�" oa ut ealth District for a permit to construct and/or install the work herein described. This application is aquin ounty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin istrict. Job Address City Lot Size PM Owner's Name -� I fWAddress ` Phone i A� License No. � �2 Phon Contractor Address , TYPE OF WELL/PUMP: KEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION R-- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION_ w_ AGRkCULTURE 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-;-�.mestic/Privat.e ❑ Gravel Pack [!3- fracy Type of Casing Specifications F] Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —Approx. Depth LI 1 Eastern Suy�ace Seal Insta]led by _ Repair Work Done ❑ Type of Pump S-ah N.P. � _._� �_. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material (Below 50') U+ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other_ Q 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 N PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property"Line 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 L! Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: "1 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 must call for all required inspections. Complete drawing on reverse side. f /� Signed X Title: _ sl� DEPARTMENT USE ONLY Application Accepted by Date �23 dF3 Area 62-16 Pit or Grout Inspection by Date Final Inspection by J pate °� 4 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, SlIk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. FO I♦. Ell 13-24(REV.i/Kr,) A ! .♦� /!!- A/EH 14-28 1111 1'�L/V /