88-125 - Laserfiche WebLink

Home Browse Search

4/io APPLICATION FOR PERMIT ;, , "�� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,, STOCKTON, CA t p,�t Telephone 12091 466-678 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .,, (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the work hereinfol >�a±�lication is made in compliance with San Joaquin County Ordinance No:549 for sewageeor No. 1862 for well/pump and the Rules and Regrfifimmo San Joaquin Local Health District.r.;tt: Job Address a o City j /1 V L Lot Size PM Owner's Name F�N ��`' Mc Address Phone j f� # Contractor Address License Nol6 j;�� Phone Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ef- OTHER ❑ V\ 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 Dia. of Well Casing 5r=Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specfications ❑ Public ❑ Other_`_,,. ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth, ❑ Eastern ' Surface Seal Installed by Repair Work Done 4 Type.of Pump; H.P. I 4' State Work Done (� Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is k available within 200 feet./ , Installation will serve: Residence—.: Commercial__-_ Other Number of living units: Number of bedrooms 3 .x Gharacter-of-soil"to a depth of 3 feet:° -- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ; PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation .Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 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." s The applicant t call for all requii d in-specti/ons. Complete drawing on reverse side. Signed We: " 7Z� Date: FOR DEPARTMENT USE ONLY / Application Accepted by13�1Date Area :. Pit or Grout Inspection by Date Final Inspection by Date J� Additional Comments: f� �W54�085❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ anteca 823-7104 ❑ Tracy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT.DUE AMOUNT REMITTED CK' RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13.24 IREV.7/s 51 EH 14-28 `