88-2308 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 'Yllf, a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.,NAZELt•NAVE„ STOCICTON, CA Telephone {2091466-6781 HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRUMENSE (Complete in Triplicate) 1RM1T/ R�lCS Applications ereby 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. Job Address City PM Owner's Name ��r ddress - PhonCJ ® /� L / /k ? Phone Contractor ) Address License No. 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantecax Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack" ❑ Tracy Type of Casing Specifications f'l Public fa Other Cl Delta Depth of Grout Seal Type of Grout i I Irrigation "' .Approx. Depth l I astern Sprfaca Seal Installed by _ Repair-Work Done Type of Pump j H.P. — State Work Done Well Destruction ❑ Well Diameter Sealing.Material (top 50') w Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l I DESTRUCTION I 1 iNo septic system permitted if public sewer is .r., available within 200 feet,I Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms r._ I Character of soil to a depth of 3 feet: 1 Water table depth Y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �_ F �, Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines +" `Ttt otal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size __ Number SUMPS Ll Distance to clearest: 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 regula he San Joaquin Local Health Di�tiict. I Home owner r licensed ent's si nature certifie following: "I certify that in the performance of the work for which this permit is issued, I shall not employ an person in suc mann a o beta su ct to-workman's compo sation laws of California."Contractors hiring or sub-contracting signature certifies a following: " rtify a pe or ce of the work for thi rmit is issued, I shall employ persons subject to workman's compensa- tion law of Californi The ap lica c for r " "ons. C plete drawing on de. lo Signed Title: Date: W 00 ;FOR DEPARTMENT USE ONLY Application Accepted by _ Date �✓ Area Pit or Grout Inspection by Date Final Inspection by Date 1,131-5v 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH13-241REV. 5) EH 1426 LU/ J