88-802 - Laserfiche WebLink

Home Browse Search

fi APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 .i (PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i . (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. Job Address �U �r C_'�f � � ??22 City Lot Size PM Owner's Name ;- A24/ t UPS Address Phone Contractor Address cense Nq. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELLr REPLACEMENT E) DESTRUCTION ❑ i PUMP INSTALLATION-J�O e4Q. . y1 S, TEM REPAIR ❑ 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 I Dia. of Well Casing ❑ Domestic/Private © Gravel Pack ❑ Tracy Type of Casing I Specifications M Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I Irrigation Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P: State Work Done �1 (a Well Destruction ❑ Well Diameter Sealing Material {top 501C7i C7 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:-Residence_____ Commercial Otherf i� I _Number of living units: Number of bedrooms z } Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity -s No. Compartments PKG. TREATMENT PLT. ❑ S Method of Disposal Distance to nearest: Well Foundation Property Line t M LEACHING LINE M❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation i'r Property Line } SEEPAGE PITS i I Depth } Size Number I SUMPS CI Distance to nearest: Well a• Foundation! Property Line DISPOSAL PONDS ❑ 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..regu lat ions of the San Joaquin Local Health District. 1 F I Home owner or ticensed agent's signature certifies the following: "I certify that in the peiformance of the work for which this permit is issued, I shall not ! employ any person in such manner as to became 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 applicantll requir _ions. Complete-drawing on-reverse de�»} i Signed X �r " T� Title: Date: "`� r� FOR flEPARTENT'USE ONLY Application Accepted by Date Area V Pit or Grout Inspection by Data .Final Inspection by Date Additional Comments: ; ❑ Stk 4bfi-fi7$1. -❑Lodi 3fi9 3fi21 W-^r'"I]"Mentec`a '8Z3-7104-0-f r aicy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE I AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH r r EH 13-241REV.1/R51 r- -- EH 1 4-2a