88-1118 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 16b1 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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. j Is Address 1• �� 1��` ��f>�r City rJf. : Lot Size_ f 1'c.�t�.� PM Owner s Name _ /' r1 nsi e•@ �.rw� Address 11y.�P Phone G Contractor &.1 - Ad $e License No. .. Phone E. TYPE OF WELL/PUMP: NEW WUCL WELL REPLACEME El DESTRUCTION { y IM; PUMP INSTALLATIt�t-�[:�f SYSTEM REPAIR ❑ OTHER I DISTANCE TO NEARE5T:_SEP- IC TANK .,! SEWER LINES X70 4h` DISPOSAL FLD. .27a PROP, LINE' FOUNDATION _._- CULTURE WELL / g OTHER WELL °-ZA2 t PITS/SUMPSa-Z t �' INTENDED USE f TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .F O lndustrial + ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation �� Dia. of Well Casing ' i ❑ Domestic/Private Ne"ravel Pack ❑ Tracy Type of Casing I Specifications wed IiI"Public t ❑ Other Cl Delta Depth of Grout Seal Type of Grout Irrigation _.-Approx. Depth � i I Eastern Surface Seal Installed J Repair Work Done ❑ Type of Pump C -� H.P._ �,` State Work Done Well Destruction ❑� Well Diameter. Sealing Material (top 501 �VAr 'ia r Depth Filler Material iBelow 50') - J TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION f I DESTRUCTION1 I (No septic system permitted if public sewer is ' available within 200 feet.) ; J r Installation will serve. Residence Commercial_ Other Number of living units: Number of bedrooms• -haractef of soil to a depth of 3 feet: TINater table depth SEPTIC TANK ❑ Type/Mfg _-_ Capacity "i No. Compartments PKG, TREATMENT PLT. 0 - Method of Disposal f 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 { 11 Depth Size Number � SUMPS i_L]—Distance,-to nearest;,,_Well-.- Foundation-n'—Property-Line DISPOSAL PONDS ❑ `=}.. rY 'ac - _.---. I hereby certify that I have prepared this application andYthat 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. t Home owner or licensed agent's signature,certifiesthe 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." T4 applicant must call for all re ired inspe tions. omplete drawing on reverse side. Signed X Title: Date: a FOR DEPARTMENT USE ONLY C i Application Accepted by Date J Area .i� Pit or Grout In i ' -Final Inspection by Date i ditional Comments: /� S Q 1 �U 5 -3 Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Ap;IantRatu;n,' all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Sik., CA 95201 ov I� FEE AMOUNT DUE AMOUNT REMITTED CA 11 INFO SH RECEIVED BY DATE PERMIT'NO. +.EH 13224 MEV.r i H 51 EH 14-28 _7 r