88-1552 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZELTON AVE., STOCKTON, C41 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 or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage. E Local health District. �j� �I,,, Job Address -7`r/ Y4 a vl City f►L� Lot Size PM 4P- Phone Address Phone C? 1 F r Address -'; ' Lieense Na. r Phone 1P 6 Conf`ractor � - _ __TYFE OF WELLJ.PUMP:_. _. . .,NEW.WELL-❑,a_,WELL REPLACEMENT ❑ � _ . DESTRUCTION ❑ _ _ � __ .4 � " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC C TANK_ '-SEWER LINES _ �\ FOUNDATION ;GRIGULTURE WELL OTHER WELL I PITS/SUMPS �] ' r - - 3 I INTENDED USE TYPE OF-WELL PROBLEM•AREA- ;CONSTRUCTION SPECIFICATIONS ..❑ Industrial, U Open Bottom ❑ Manteca y ia. of Well Excavation Dia. of Well Casing __ I C Domestic/Private O Gravel Pack ❑ Tracery Type of Casing Specifications °^ Type of Grout f I Pubtic n Other F1 Delta - Depth of Grout Seal I I Irrigation y _Approx. Depth I 1 Eastern Surface Seal Installed by s: ; Repair"Work Done 0- Type of Pump H.P. State Work Done _ Well Destruction ❑ �=Well Diameter Sealing Material (top 501 t "Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR IADDITION pESTRUCTION l I (No septic system permitteti available within 200 feet.) G � � _ Installation will serve:�Residence Commercial_ Other T J Number of living units: � Number of.bedrooms Character of soil to a'depih of 3 feet:5 �'�'►�' Water table depth SEPTIC TANK-- ''❑ Type/Mfg Capacity # No. Compartments ` Method of Disposal PKG. TREATMENT_ PLT_. ❑�.�...,,.y 4 ... ....w.. _-i_ _ - ,., --.,.- -_. .-.-._ -- ,, *{ Distance to nearest: Well Foundation Property Line LEAC.HtNG LINE _❑_ No. & Length of lines Total length/size FILTER BED ' .❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number ' I SUMPS Distance to nearest: Well Foundation Property Line' _. r DISPOSAL PONDS ❑ I hereby certify that I have prepared tftis applicarion and that,the_work-will be.done_in ac_cordance witb-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 employ persons subject to workman's compensa- tion laws of California." The applicant must call for all re fired inspections. Complete drawing on reverse side. -A - ,- '� S Date: S # Signed X_i,ts Title: — ; E r I FO ARTMENT USE ONLY _ A lication Accepted by_. ✓ Date. Area. --# PP P.... PitJor Grout Inspection by Date Final Inspection b Date or Comments: ❑ Stk 466-6781 L1 Lodi 369-3621 C7 Manteca 823-7104 0 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 GASH RECEIVED BY DATE PERMIT'NO. INFO € � EH 13-24(REV.E/k 51 - �D ` EH 14-26 y y