88-1065 - Laserfiche WebLink

Home Browse Search

N APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 'w � - 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 Na. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. s. Job Address )P41City of Size/ PM r r Owner's NameAq� dress, _ 9!�s'Dt�[ 'r � Phone 2B _. F Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES %! DISPOSAL FLD. . PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications D . (-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 41 Depth Filler Material lBelow 501 . TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION><INo septic system permitted if public sewer is ,1 t 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: F' Water table depth ....SEPTIC TANK ❑ Type/Mfg Capacity-'f No. Compartments PKG. TREATMENT PLT. ❑ .,� Method of Disposal. Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines w .Total length/size FILTER BED/ ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth - Size Number _r SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL_PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordancewithSan 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 m call for all required inspections. Comple rawing on reverse side. Signed Title: Date: ' F. R MIRRASMENT USE ONLY 1 Application Accepted by _-�-- t 1 Sh Date _� Area Pit or Grout Inspection by Date Final Inspection b Dat fl- Additional Comments: �/ Y S ❑ Stk 466-6781 ❑ Lod' 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 Al/NOU�tNwT DUE pAMO/UNT REMITTED CK CASH RECEIVED BY DATE PERM�IIT'NO. EH 14-263-24 IREV, 4-24IREY.1/651 ILD✓a,'"V W� � �tl �G✓h, /� � ��r�� / .