88-764 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT Vd / s SAN JOAQUIN LOCAL HEALTH DISTRICT A� . 1601 E. HAZELTON AVE., STOCKTON, CA ¢tJst�Pn we�G I: Telephone 12091 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 andlor 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 i Local Health District- Job Address /7y6 CityLot Size . •o �Pn �!f°d Jr��♦L! _� Address �fJ �/f'!E+(P �✓/� _ Y""C�� Phone i Owner's Name 40-10 tr 9J-��2_ r� y Contractor*10A( Address t ' License No. Phone TYPE OF WMP: N WELL r� WELI REPLACEMENT ❑ DESTRUCTION ❑ `1 PUMP INSTALLATION)W SYSTEM REPAIR ❑ OTHER ❑ �1 ° DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ — _FOUNDATION AGRICULTURE.WELL- -_ OTHER-WELL , �P1T51'Sl1MPS' � (� w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `� LiIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private P,Gravel Pack ❑ Tracy Type of Casing /disc /Z42 Specifications ['l Public ti F-1 Other F-1 Delta Depth of Grout Seal r Type of Grout_.�,&,dtPAI --.. 1 1 Irrigation ,tr —_..Approx. Depth I 1 Eastern Surface Seal Installed by _,Repair Work-Done--❑" Type of-Pump -= H..P_ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 60') TYPE OF SEPTIC WORK: NEW INSTALLATION [] REPAIR/ADDITION ( I DESTRUCTION I I aNailableo septic systithinem emitted if public sewer is 3, Installation will serve: Residence_ Commercial_ Other i f _ 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. D Method of Disposal Distance to nearest: Well Foundation Property,Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number �1 SUMPS Ll Distance to nearest: Well Foundation Property AskY i E14T DISPOSAL PONDS ❑ #----R E CE I'VE D 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. 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��(�t } 1j6� t tgm"n"s compensa- tion laws of California." PERMITISERVICES The applicant must ca for all quired inspec'ons. Complete drawing on reverse side Signed 4 &!A&_ ! d Date: �D FOR DEPARTMENT USE ONLY si / Application Accepted by Date .4 Area Qi f Pit or Grout Inspection by Date Final Inspection by Additional Comments: /J i ❑ Stk 466-6781 Ll Lodi 3694621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 J� I 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 CASH RECEIVED BY DATE PERMIT-NO. INFO +.EH 1320 I REV.i/A 51 fl EH 14-M