88-1781 - Laserfiche WebLink

Home Browse Search

". APPLICATION FOR PERMIT t 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 con tract and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for M, age- made f well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City of Size PM i r Owner's Name Address Phone "Contract rte Address lo, -- License No < 22 1--Phone,�V�191 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f'�Z =1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing :❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications p� n Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout - t I Irrigation _.Approx. Depth I I Eastern Surface Seal installed by T Repair Work Done ❑ Type of Pump H.P. State Work Doney ,Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/,ADDITION [ I DESTRUCTION I I (No septic system permitted if public sewer is C, available within 200 feet.) Installation will serve: R idence Commercial Other _ f Number of living units: Numb*oroomsCharacter of soil to a depth of 3 feet: ` Water table depthSEPTIC TANK Type/Mfg Capacity��l - No: Compartments PKG. TREATMENT PLT. ❑ - , .* (� �-, F 'Method of Disppsa) Distance to nearest: Well �'� _-.Foundation 40 Property Line 0 te LEACHING LINE No. & Length of lines Total length/siz FILTER SED ❑ Distance to nearest: Well Foundation //) Property Line x a SEEPAGE PITS I I Depth Size' Number SUMPS 0 Distance to nearest:_, -WellFoundation Property Line # DISPOSAL PONDS I hereby certify that l 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: "1 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. f California." The applicant m call for all ire spections. Complete drawing on reverse side. Signed X Title: Date: r 4" 1 FOR DEPARTMENT USE ONLY Application Accepted by �� - Date Area Pit or Grout Inspection by Date Final Inspection by Additional Comments:'�-I Z- e � ;�- = Z� LI Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 836-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO SA/f�f(/�JCASH.1lJ l/ +.EM1314(REV.t/H5) EH 14-28