88-297 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA # Telephone (209) 466-6781 S 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. Job Addres �• City ' Lot Size PM QCt1 Q � Address ;"�- Phone 00 Owner's Name �e,�.� Contract Address PQ 70 6 dw License No, a Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - _PUMP INSTALLATION ❑ SYSTEM REPAIR,[] Fes_ -_OTHER ❑_._-- __ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS n T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -❑ Industrial i]-Open Bottom•-- 171-Manteca Dia. of Well Excavation --- Dia..of Well.Casing ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing r Specifications ❑ Public f1 Other ❑ Delta Depth of Grout Seal '- Type of Grout — I I Irrigation —"Approx. Depth i I Eastern Surface Seal Installed by� t- - Repair Work Hone ❑ Type of Pump H.P. State Work Done Well Destruction ElWell Diameter --- —Sealing.Material dtop-50'1 Depth filler Material (Below 501 } J TYPE OF SEPTIC WORK: NEW INSTALLATION I /ADDITION I DESTRUCTION ( I (Na septic system perm REPAIitted if public sewer is available within 200 feet.I Installation will serve: Residence Commercial Other Number of living units: / Number of be r oms Character of soil to a depth of 3 feet: Water table depth 7 F Compartments SEPTIC TANK - f=J Type/Mfg Capacity No. Co p f j PKG. TREATMENT PLT. Method of Disposal❑ 'T r . Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: ' Well Foundation_f�r Property Line .S SEEPAGE PITS l'I Depth _ �Q Size�X l0 Number SUMPS kr�Distance to nearest: Well �QL�f;. Foundation_/Of Property Line i DISPOSAL PONDS O 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 m call for req red inspections. Complete drawing on reverse de. q rf Title: r Date: I FOR DEPARTMENT USE ONLY App' ation Accepted byDate . Area eZ / x I r Jor Grout Inspection by D to Final Inspection by Date 2 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 U Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2f>09, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO i t EH 13-24 titEV,I/y 51 0 EH t4-26