88-612 - Laserfiche WebLink

Home Browse Search

T % s` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR`FROM DATE ISSUED p ` (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. I� Job Address City � C� Lot Size PM Owner's Name I�. L 1 Address Phone I Contractor Address License No. Phone ' TYPE OF WELL/PUMP: !I NEW.WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ x PUMP INSTALLATION ❑ SYSTEMREPAIR ❑ OTHER ❑ ,r { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL �,,PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LJ Open Bottom-Q,-,,❑ Manteca ; Dia.-ofWell Excavation Dia. of Well Casing ` L] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other - 17 Delta Depth of Grout Seal Type of Grout _ I I Irrigation _..Approx. Depth I i Eastern Surface Seat Installed by ' Repair Work Done ❑ Type of Pump H.P. State Work Done �. Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth` Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION l I DESTRUCTION Wo septic system permitted if public sewer 11 . is f \`~ available within 200 feet.) Installation will serve: Residence— Commercial_1 Other Number of living units: �� Number of bedrooms_ L Character of soil to a depth of(3 feet: Water table depth r SEPTIC TANK ❑ Tyjj)e/Mfg Capacity No. Compartments n PKG. TREATMENT PLT. ❑ ;I Method of Disposal Distance to nearest: Well m Foundation Property Line LEACHING LINE ❑ No� & Length of lines ` Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth - Sire Number t SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 IM � 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 shalt 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 a 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." all req The applicant must call for uired ins t _ q peytions/. Cofnple�te�dyra�wing on reverse side. - Signe,*,<,' FOR DEPARTMENT USE ONLY Application Accepted by Date -'�� Area Pit or Grout Inspection by I� Date Final Inspection by 1 Date Additional Comments: �— k/t I L R� "Al /o ti_ d 4 t C.f1 I� � ❑ 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;DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 3-24 v EH 14-26 IREV.1/N 5F �/ <-;o:;Z Awl, 1g, Q 99 L9 If �