88-1638 - Laserfiche WebLink

Home Browse Search

y o APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �&v l D l �0 City 1-5r `t6f Size PM Owner's Name`1)(?4 Yf_$ 1p it Z7 Address M.— - e Phone Contractor f//��,�tv.,�� 77AL Address �� C_rek-eLicenseNo.J�a�Phone O� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR �rJ' OTHER ❑ 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 5eDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public fl Other 17:1 Delta Depth of Grout Seal Type of Grout I I Irrigation —..Approx. Depth I Eastern Surf a Seal Installed by Repair Work Done Ir Type of Pump H.P. State Work Done JF 14'r Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 ; TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I Wo septic system permitted if public sewer is available within 200 feet.) 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. ❑ Method of Disposal Distance to nearest: WellFoundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS C] 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 District. I k - ~[� J 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 parson in such manner as to become subject to workman's compensation taws 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 applict call for all require specti s. Co ate drawing on reverse side. Signed X Title: -�i�j AS Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by �7/ n 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 E F" INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 13.241REV.1/951 EH t4-28 VV