88-305 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 AJo. 62 f�r well/pump and the Rules and Regulations of the San Joaquin Local Health District. >� Job Address e6 31 k !^ ✓ City Lot Size PM LU 49W Owner's Name SAL, �L�r �I A dress �s / Phone Contractor '� rlY i Address License Noy S�Phone t TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,.q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE 1 , -FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS "V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing R ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy - 'type of Casing Specifications r l`I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout. I I Irrigation f. _._Approx. Depth I I Eastern Surface Seal Installed by _ r 4 Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 f Depth Filler Material /Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION JKA REPAIR/ADDITION I I DESTRUCTION I 1 {No septic system permitted if public sewer is available within 200 feet) e Installation will serve: Residence Commercial— Other ` Number of living units: Number of edrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK A—Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r Z/V LEACHING LINE ❑ No. & Length of lines " Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line '•SEEPAGE PITS 11 Depth � ize �� l umber SUMPS i Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1•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"Seh'Joequin Local Health District. Home owner or licensed agent's signatu?6 certifies the following�l certify that-in the perfbfmance 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 foilowing: ''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 Californ' / The applicant mu II for all r uired i ctions. Complgte drawing on r e e side. i Signed X - Title: Date: Al (d/ r - FA&6EPARTrENT USE ONLY Jr Application Accepted by Date Area ? �// ,. Pit or Grout Inspection by - Date Final Inspection by Date Additional Comments: ❑ Stk .466-6781 ❑ Lodi 369-3621. ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 + EH13-24(REV. , 41 EH t4-26 Y '. r