88-2383 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) -•--•-Application is hereby ma to the 5 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. cc Job Address �D City N�l� � �ot 5ize P �K)U IC E. �it1 Owner's Name r I ! M-� } f __ — Address -�V 7& CJqm&n�a i ��ftn9. Phone Conlrac for �u m �U ddress 17�'iG( 1 R11A�License No.��L Phone TYPE OF WELL/PUMP: NEW WELL 4 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAI_LAT ON SYSTEM REPy41R ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE �C �a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L WSJ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private `Gravel Pack ❑ Tracy Type of Casing 3P&_k Specifications r Public (� Other P Delta Depth of Grout Seal Type of Grout I Irrigation --Approx. De ,1 Eastern Su .Sea! Installed by _ Repair Work Done C� Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 501 _y TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION I 1 lNo septic system permitted if public sewer is available within 200 feet.] 1 Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC/TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f i # Method of Disposal r Distance to nearest: ' Well 'Foundation v Property.Line , LEACHING LINE ❑ No. & Length of lines / r Total length/size FILTER BED ❑ Distance to nearest: Well * Foundation Property Line SEEPAGE PITS l I Depth Size Number "SUMPS Ll Distance to nearest: 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,-sfate laws, and rules and regulations of the San Joaquin Local Health Diktrict.. ; 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the pelorrflance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The applica rr�Y�call for all require inspectio9s. Completedraw' g on reverse side, ,�y� Signed itle: �r�)///�� Date: FO DEPARTMENT USE ONLY ry Application Accepted by _.__. .._ Date 7, ) Area Pit or Grout fnspectio Duta q/15W_ Final Inspection by Date J1—L=Q9-- Additional Comments: -❑ Stk 466-6781 ❑ Lodi 369-3621 ID 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 C RECEIVED BY DATE PERMI7'NO. INFOCA1/SH 4EH EH13-24IREV.tinsl - 5 544 cP3A'zC _air i