88-1970 - 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 I1 v PERMIT EXPIRES 'f 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. 6�l Scd �i,` / l Cit Job Address — ,. S � Y��.TIJ., y �pAl� „�._. Lot Size J��t/�,,p PM Owner's Name -415 TeeAj 124L, _ Address 2 7 7 /' Phone 45 Contractor /+ G c Address Al 460,40 4L License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation / # pia. of Well Casing ADomestic/Private Gravel Pack ❑ Tracy Type of Casing ,�._ Specifications IdZ5 / M Public ❑ Other ❑ Delta Depth of Grout Seal /� mm Type of Grout I I irrigation ---Approx. Depth I 1 Eastern Surface Seal Installed by—,.. Repair Work.Done ❑ Type of Pump �5--", H.P- 1,7 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION !1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is r available within 2Wfeet.) Installation will serve: Residence_ Commercial_ Other �r Number of living units: Number of bedrooms 1 rJ 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 Distance to nearest: Well Foundation ' Property Line LEACHING LINE ❑ -NU. & Length of lines T Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health Oiltrict. 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 shalt 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 must c II for all required ins cti ns. Complete drawing on reverse side. al Signed X Title: Date: R DEPARTMENT USE ONLY Application Accepted by / (J� Date 'PI~ Area Pit or Grout Inspection by Date ` j Final Inspection by 1 Date 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 J., FEE INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED By DATE PERMIT'NO. +.EH 13-24 1REV.I/H 5) - - Z' Y711 EH 14.26 D .�� - c.2 _