88-2708 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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 No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name _.Cdc� Address Phone ContractorAddress V Q Jbs^7� Phon �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPINSTALLATION ❑ SYSTEM 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 f ❑ Industrial t ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Lam] 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _- (-,n I I Irrigation �.Approx. Depth l I Eastern Surface Seal installed by - \�1 Repair Work Done ❑ Type of Pump H.P. State Work Done a Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence / Commercial Other r Number of living units: __L-' Number of bedrooms 2.L'1 ' ) � Character of soil to a depth of 3 feet: M r - Water table depth 4 t SEPTIC TANK -t ur TypelMfgs u � --Capacity No. Compartments PKG. TREATMENT PCT- ❑ t ) Method of Disposal 1 Distance to nearest: We _.... Foundation Property Line - .�-- LEACHING LINE Fr-No l. & Length of lines 0 _Tgtal length/size dr t FILTER BED LJ Distance to nearest: Well/�O Foundation cP 1 Property Line aj SEEPAGE PITS P Depth .. '------Size 3 fd ,Number_ SUMPS L7 ;Distance to nearest: Well Q_ Foundation ''� Property Line/ ?U z DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that she work will be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health Diktrict. 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 must call f r all pequired inspections. Complete drawing on reverse side. . t Signed X� Title: Date: 1011"y T FOR DEPARTMENT USE ONLY _ Application Accepted by Date Area Pit r Grout Inspection by Date �I final Inspection by / / �/O'�A,g�c.�� Date 9 a. Additional Comments. ❑ Stk 466-6781 ❑ Lodi 369-3621 '❑ Manteca 823-7104- - ❑ Tracy-835=6385 — W Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH 1324' 4 REV.I/K 51 - r EH 14-28