88-1116 - Laserfiche WebLink

Home Browse Search

` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE-TON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Address /�� / ZY C 6 m49 FC -` CitySk3 f3 1V' Lot Size PM 40wner's•Name6/ )TZLress T41fIJfL�6gma/f /Yip Phone �£ontractor_p Address License No. Phone !TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \ _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF-WELL PROBLEM AREA.- CONSTRUCTION SPECIFICATIONS �--� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t {� ❑ Domestic/Private _❑_Gravel Pack ❑ Tracy Type of Casing Specifications t"1 Public ❑ Other—1.'— ❑ Delta Depth of Grout Seal� Type of Grout _ 11 Irrigation _-Approxi Depth I-I Eastern Surface Seal Installed by _ 4 `Re air Work:Done ❑ Type of Purr!" H.P. State Work Done_ p YP �.. � Well Destruction ❑ Well Diameter Sealing Material {top 50'1 t - Depth Filler Material {Below 501 s TYPE-OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION (No se tics stem permitted if p y p public sewer is 17 available within 200 feet.! Installation will serve: Residence Commercial__W._ 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size " I FILTER BED '❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well foundation Property Line { DISPOSAL PONDS ❑ r { , 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 D1iltrict. _ m 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 must call for all require inspections. Gompleta drawing on reverse side. � � � Signed X itlelL Dater S lr;Jl �1 x - F FOR DEPARTMENT USE ONLY Application Accepted by { Date S�`S! _7E Area Pit or Grout Inspection by + Date Final Inspection by 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 FEE INFO AMOUNT DUET AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. t !` _ 6 ♦.EH 143-24iREV.tins) J �,� CGli� S'��y J( I . EH 14-28 l� Cl