88-2500 - Laserfiche WebLink

Home Browse Search

M APPLICATION FOR PERMIT SAN JOAQUIN L6�AL 4rAft f3f fiR�C'�° SAN JOAQUIN LOCAL HEALTH DISTRICT ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE., STOCKTON, CA SPECIAL: PERMIT Telephone (209) 466-6781 PERMIT EXPIRES 9 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 No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address :^ �' City �&,gZW Lot Size PM Owner's Name Address ` � Phone Ik64. —3 Cantractor� l A a'W �f _Yi/�C( __ Address 8.49ftl_44* 4f License No$ - Phone f. Q0 TYPE OF WELL/PUMP: NEIN WELL WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR LJ OTHER El DISTANCE TO NEAREST: SEPTIC TANP�� SEWER LINE��i�� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial T ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ SrXAF_0f_ __ Specifications [-I Public X�OOtnthe �` ❑ Delta Depth of Grout Seal m 0 Type of Grout r 1 1 Irrigation lAp rox. fTep`th 1-1 Eastern ` Surface Seal Installed by &y e-1Ari Repair Work Done ❑ Type of Pump . �/' H.P. `Z— State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line s LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 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, and rules and regulations of the San Joaquin Local Health Di§trict. 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 certif hat in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." The applicant m ca all require do io . omplete drawing on re rse side. Signed X Title: ¢fLi Date: Ifs- FOR DEPARTMENT USE ONLY Application Accepted by / Date�f�L� V V Area Pit or Grout inspection by Date 1SL[2 g.._ ._ Final Inspection by �� Sk Date l / Additional Comments: +oe ai" ❑ 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 C SN RECEIVED BY DATE PERMIT-NO. 1 —41 EH 14-26 ♦.EH 13-24(REV.1 i n 5) 3S�1 ��// - t