88-1557 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 fE. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -1tbr:ol `0 {Complete in Triplicate) pli �_ ... � 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 Riles and Regulations of the San Joaquin Local Health District. `', 8 A P ' RtJ. >4. , Jab Address � "- - City Lot Size a. a PM Owner's Nam x. Addressk a� ; ^-'r ' �-�' ---_ Phone –0i 6J Contractor J� " € ddress TYPE OF WELL/PUMP: License'No, Phone NEW WELL ❑ WE LAC M NT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEMfiEPAIR ❑ t DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ � SEWER LINES DISPOSAL FLD. i PROP. LINE +' FOUNDATION �"""AGRICtlLTURE � OTHER WELL PITS/SUMPS iINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `. ❑ ndustr!al ❑ Open Bottom ❑ Manteca - x Dia. of Well Excavation .}Dia. of Wel! Casing Domestic/Private EJ Gravel Pack ❑ Trac �` I ❑ Public y Type of Casing Specifications f ❑ Other ❑ Delta Depth of'Grout Sea! ` ❑ Irrigation ,Approx. Dept �'p1�� Eastern W Type of Grout Repair Work Done ❑ Type of Pump � ^. P Surface Seal Installed by { r H.P. Well Destruction ❑ Well Diameter-� r State Work Donk rr Sealing Material (top 50'} ICA I A h ! PDepihr f. r ' Filler Material (Below 501) UIJIPr1 �E � A TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is WIN F ' 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: a f SEPTIC TANK ❑ Type/Mfg I Waterlable depth PKG. TREATMENT PLT. ❑ Capacity Noy Compartments i V`;- Method of Disposal Distance to nearest: Well Foundation P ,� a. –�_ Property Line's t % + LEACHING LINE ❑ No. & Length of lines -- w� FILTER BED ❑ Distance to neares: Total length/size 9 f 1 �- Well- Foundation Property Line ` SEEPAGE PITS ❑ Depth Site SUiVfPS Number f ❑ Distance tone rest: ?1Nell'f Foundation DISPOSAL PONDS` 'q Property Line " I hereby certify that I have re aced this application and that he work will be done in accordance 3 rules and regulations of the San Joaquin Local Health District. ce with San Joaquin county ordinances, state Laws, and Home owner or licensed agerit's signature certifie8 the fofiowingi"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 certlfles the following:""i certify that•in•the•pertFormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion,iaws of California." TheFappGcust call for all required inspections. Complete drawing on reverse side. { t )(Sig ed Title: - _ Date: C5 C] FOR DEPARTMENT USE ONLY Application Accepted by j g Date r Area k Pit or Grout Inspection by I Date Final Inspection by / `L E Date(1�1 Additional Comments: � ,� _ t !! --"" 1 A Sic 466-6781 LJ Lodi 369-3621 EI Manteca 823-7104 ❑ Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ; INFO AMOUNT DUE AMOUNT REMITTED, RECEIVED BY 'DATE' - EPCRM .+ EH 1324{REV,7/a 5) EH 142617 k