88-2020 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 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. Oji h / Job Address E- �� Gity Lot Size 2��+ 2-L / PM Owner's NameUN�u Address 13: 12 .,/ Phone Contract �• 577�� Atldress; ry ��kL License No, /7d P hone TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT19PS tI LA "A ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavatio Dia. of Well Casing Co Domestic/Privates Gravel PackTracy Type of Casing Specifications 1-1 Public Cl Other Cl Delta Depth of Grout Seal �f /zoo Type of Grout _. I I Irrigation Approx. Depth t I Eastern f ace Seal Installed by ff Repair Work Done ❑ Type of Pump S'A= H.P. V State Work Done Well Destruction ❑ Well Diameter Sealing M serial (top 50'1 Depth Filler Material I Below 501 _,...,. . ._...,.__.,_-....... -.. ._.,__. � TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I (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 11 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 PITS ( I Depth Size _ Number SUMPS Ll 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 Diltrict. 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 Californi ' The applicant m t I f r all req 'e nspections. Complete drawing on re or side. _ Signed X x Title: Date: e4 F DEPARTMENT USE ONLY �f{� Application Accepted by Date 9 A Area PitGrout i fraction by to /Y 1 X Final Inspection by_ ate= Q Additiana Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823h' 104 ❑ T acy -6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I CK INFO /AMOUNT DUDE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH13-21 IREV. EH 14-26 !/