88-2501 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCA[ WA[�'K �'f� kft I � SAN JOAQUIN LOCAL HEALTH DISTRICT ENVIRONMENTAL HCS,.'.-Y_ DIVISION 1601 E. HAZEL T ON AVE., STOCKTON, CA SPEW&. " 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 welUpump and the Rules and Regulations of the San Joaquin local Health District. _r Job Addresses v 7 S"` City of Size PM Address hone Owner's NamA .DO '�' �" k f� Address Fi.� License No.✓ � �� m t Contractor �t/�L V/ r (!\ . TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT © DESTRUCTION ❑ i PUMP INSTALLATION )a SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK 72--Z^r/ SEWER LINES —Z C-/ DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI ATI S p s` f Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ _ Dia. of Well Casing ❑ Domestic/Private IrGravel Pack - ElTracy Type of Casing f � SpecificationsT - 171 Public Otha E"17V j" 171 Delta Depth of Grout Seal Type of Grouf � I I Irrigation EAppraepth l I Eastern urface Seal Installed by y - Repair Work Done ❑ Type of Pump !Yt H.P. / State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION l 1 DESTRUCTION I I (No 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 r Distance to nearest: Well Foundation Property Line length/size I LEACHING LINE ❑ No. & Length of lines Total len g FILTER BED ❑ Distance to nearest: Well Foundation Property line j SEEPAGE PITS VI Depth Size _ Number SUMPS Li" Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS D 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. 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 tb become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in th 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 m or all re d in o omplete drawing on rev side. �Q Signed X Title: h� Date; FOR DEPARTMENT USE ONLY r pate Area 4 Application Accepted by t n Pit or Grout Inspection by Dat Final Inspection by (T Data Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 0 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 AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. INFO +.EH 1324(REV.i/115) EH 14-26