88-2453 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (200) 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. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r ` r� Y Job Address bY.www VI'jOral sPrJ�� _ SbvG Pa Cr t,_Ci �+ �J G/t�fNet'Size PM ` , 5+Lhh O-K- I1Ia I kt�CYLC� Owner's Name 0 60 C4.1 (D r D Address Z17cs A)' 6:040Y-S,14- R 1✓d phone ff– f 4cr 76 7 Ey�nn� i5 21VL 0 S Q- 8 XP#e!!�Lf`or► 6e � r �.._Phone -6 Contractor ress f r License Na. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U.)&115 YL k). PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4 IM l v 7 DISTANCE TO NEAREST: SEPTIC TANK > 1 SEWER LINES y41151 DISPOSAL FLD. :'� PROP. LINE Q FOUNDATION �`rd f AGRICULTURE WELL St�� 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction El Well Diameter Sealing Material (top 501 G_7_ Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PPTS ❑ Depth Size Number SUMPS ❑ Distance to nearest: ' Well Foundation Property Line 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 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. Signed Title: `� Data: p E ONLY Application Accepted by Date Area Pit or Grout Ins pe i y Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2809, Stlk CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDL�Sy RECEIVED BY DATE PERMIT NO. INFO + EH 1324IREV.1/e51 � s 9 � EH 1426 ✓✓