88-480 - Laserfiche WebLink

Home Browse Search

V +� APPLICATION FOR PERMIT G V SAN JOAQUIN LOCAL HEALTH DISTRICT hS 6 1601 E. HAZEL 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. fj Job Address City Lot Size PM OwnerrIs NNa-�me w Address Phone Cantractol r f k �r_(Pi5idress—5-1 —esn�1 am License Nn Phone TYPE OF WELL/PUMP: NEW WELL 1!�— WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION I+--y SYSTEM REPAIR © //OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES XI!2 DISPOSAL FLD/ ROP. LINE FOUNDATION AGRICULTURE WELL/ kkQ OTHER WELL_,()&2!_(_PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� k ❑ Industrial &J-trp'en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing / Cz}`Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' 1 Ll Public (71 Other n Delta Depth of Grout Seal e2::7) Type of Grout I I Irrigation —__.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done LtY ype of Pump SSC46M H.P. o'Z State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') , Q, TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is r W I available within 200 feet.) Installation will serve: Residence_ Commercial_ Other (� Number of living units: Number of bedrooms e 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 i �J Distance to nearest: Well Foundation Property Line LEACHING LINE, ❑ No..& � ngth of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth l - Size _ Number SUMPS Ll Distance to nearest: Well jFoundation Property Line DISPOSAL PONDS- •❑ .. ` 4- — l I hereby certify that I have prepared.this application-and that,the work.will be,done in-accordance with..San_Joaquin_courity-,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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant,m t call for all requir ons. Cmplete draw � on reverse side. Signed X :=i:spect t isle: ni /0�_ Date: ,5177 . �FOEPARTMENT USE ONLY Q � Application Accepted by Ott(3 $t- O`^�-�-_—— Date Area Pit or Grout Inspection by Date Final Inspection by Date._.._._� Additional Comments: ' i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 VJ� Applicant - Return all copies to: Environmental Health Permit/Services,16d1;E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 j FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMITNO. INFO /��( /(�] a CASH 7 cX7 + EH 13-24IREV.1ik511d.�(JU /� V{! 3Q0�' `�� / U EH 14-2B CVJ ff