88-1287 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT L - " SAN JOAQUIN LOCAL HEALTH DISTRICT w.,e 1601 E. HAZEL T ON AVE., STOCKTON, CA tl Telephone (209) 466-6781 PERMIT EXPIRES T 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 i Local Health District. a Job Address QJn T •" CityLot Size PM Owner's Name (21YL r�7 Address �O S Phone E Contractor �� Address License No. Phone i 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 or-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom L1 Manteca Dia. of Well Excavation Dia. of Well Casing LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public ❑ Other # ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation . Approx. Depth I ) Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction LJ Well Diameter Sealing Material (top 501 (� Depth Filler Material (Below 501 x{11 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1- REPAIR/ADDITION 1 1 DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercials Other Number of living units: Number of bedrooms R, Character of soil to a depth of 3 feet: , Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distancelto nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance#to nearest: Well Foundation A 'Property Line 41 SEEPAGE PITS 11 Depth Size Number x SUMPS ❑ Distance'to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J 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."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." The applicant must call for ail required inspections. Complete drawing on reverse side. g Titlei Date: �2 FOR DEPARTMENT USE ONLY Application Accepted by Date Area cp Pit or Grout Inspection by Date Final.Inspection by Date p y Additional Comments: —AL1 J'3 ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED 1 11, CK RECEIVED BY DATE PERMIT'NO. +..EH 13-24(FEY.11K5) Facr _,rn •�-EH 11-28 i