88-1668 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON-AVE..; STOCKTON, CA f Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. la62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 4 / ` � • . Cit4 Lot Size_ .5 2Opm Owner's Names Z Address , Phone Contrac.� r d� IAds License No. -_ Phone_ - YPE OF WELL/F,UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER _❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP.-LINE I FOOqt>ATION AGRICULTURE VILE OTHER WELL PITS/SUMPS II INTENDED U3f TYPE OF W PROBLEM CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom nteca Dia:O't.Well Excavation t°---_...Ria. of Well Casing. E ❑ Domestic/Private r ❑ Gravel Pack ❑ r 7 e of Casin 4W.- yr _ yP 9 Specifications , f-1 Publicsy.r �[ ],Oth _ ❑_Delta Depth of Grout Seat _ v ype of Grout— Sur rout r= I`I Irrigation Appro �Depih l I Eastern Surface Seal Installed by W -- I Repair Work Done II" Type of Pump H.P. State Work Done ~� 1 Well Destruction `�❑.-.Well Diameter Sealing Material (top 501 { Depth Filler Material (Below 50') TYPE OF SEPTIC,WORK: ANEW INSTALLATION I 1 RFF`AtR/ADDITION I i DESTRUCTION INo septic system,permitted if public sewer ism, available within 2{)a feet.} C. Installation will serve: Residence Commercial_ Other5 �y Number of living units: Number of bedrooms r Y Character of soil to a depth of 3 feet' Water table depth: SEPTIC TANK I ❑ Type/Mfg Capacity No. Compartments f PKC. TREATMENT-d� ' Method of Disposal Distance to nearest: Well Foundation PropertyLine LEACHING LINE 0 No. &Length of lines � � -Total length/size =- FILTER BED ❑ Distance to,nearest: Well Foundation Property Line J} I. SEEPAGE PITS-'. I''I ,Depth) Size Number `f SUMPS f ❑ 'Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ s I hereby certify that I have prepared'this.application•and-that-the-work-will-he-done-in-accordance-with-San Joaquin-county ordinances, state lawsand n rules and regulations of the San Joaquin Local Health District. fJ 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 persoh 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 aiifornia." - ` I The applica must call for all require inspection Complete drawing on reverse side. Signed X Title: �C_'! C Air+_—�-- . Date: FOR DEPARTMENT USE ONLY i Applicatr%on-Accepted byf Date Are Pit or Gr661 Inspection by= Date Final Inspection by ate Additional Comments ❑ Stk 466-6781 ' ❑ Lodi 369-3621 ❑ Manteca -823-7104 El Tracy 835=6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 ! FEE t AMOUNT DUE AMOUNT REMITTED CK --RECEIVED BY _DATE_ PERMIT"NO. INFO SH _ - - -- -.. -- - I -� 1 .-EH 14-24(flEV.1/85) al__J �� 06 1<,q01