88-1179 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT -C I SAN JOAQUIN LOCAL HEALTH DISTRICT p,`I }Sig 1601 E. HAZELTON AVE., STOCKTON, CA � G I Telephone (209) 466-6781 } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �* ONM�N�A��Gtis ` Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the woyAtriereir�¢to,kIBR his application is made in compliance with Sari Joaquin Cb unty Ordinance No. 549 for sewage or No. 1862 for well/pump and the-Rules and egulations of the San Joaquin I Local Health District. Job Address 1107A City Lot Size PM Owner's Name Address Phone e Contractor yeb e Address License No, r phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Z DISTANCE TO NEAREST:..SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER.WECC � PITS/SUMPS T— INTENDED USE TYPE OF WELL PROBLEM AREA -,CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing It Domestic/Private ❑ Gravel Pack ❑ Tracy Type'af Casing Specifications I'1 Public f=1 Other I i=l Delta Depth of Grout Sea] Type of Grout I I Irrigation _-Approxi Depth I I Eastern Surface Seal Installed by - Repair Work Done Type of PumaP..dAd .--' H.P.L _ I State Work Donee .& Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I ) DESTRUCTION I 1 (No septic system permitted if public sewer is I L. available within 200 feet.) Installation will serve: Residence Commercial— Otherw, Number of living units: Number of bedrooms Character of soil to a depth of 3;feet:' " Water table depth SEPTIC TANK ❑ Type/Mfg. I Capacity ^ . No. Compartments PKG. TREATMENT PLT. ❑ t "' s +', F Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance io nearest: Well Foundation T� Property Line SEEPAGE PITS I ) Depth 9 Sizei Number '� SUMPS ❑ Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ hereby certify that t 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 Di§trict. 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."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 f all required inspections. Complete drawing on-rev side. Signed w get Title: .S. Dater FOR DEP RTMENT USE ONLY 4 11 T Application Accepted by Pit or Grout Inspection by { Date Final Inspection by Date`� o Additional Comments: + ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CITracy 835-6385 Applicant - Return all copies to: Environmentai Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT N0. #.EH 13-24 IREV.1/H 51 _ "�^. �! EH 14-29 S