88-3151 - Laserfiche WebLink

Home Browse Search

�% APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA 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 incompliance 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 Lot Size PM Owner's Name ress ' Phone ` �2 I� P i t ansa No. hone Contractor r s TYPE OF WELLIPUMP: l NEW WELLr WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1-1 ( „ 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 ElIndustrial ❑ Dia. of Well Casing Bottom ❑ Manteca Dia. of Well Excavation 9 Type of CasingSpecifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yP } FI PublicH Other, ; F] Delta Depth of Grout Seal Type of Grout _. I I Irrigation —.-Approx. Depth I I EasternSurface Seal Installed by - ` H.P. _ State Work Done T q Repair Work Done ❑ Type of Pump . I # Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Y1 REPAIMADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) \v' Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms_' '' t Character of soil to a dap 3 feet: Water table depth SEPTIC TANK ❑ .Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ J Method of D' osal Distance to nearest: Well `�7"" Foundation l__LL— Property.Line�— _ a LEACHING LINE ❑ No. & Length of lines °�' To al length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS �. ❑ Distance to nearest: Welt oun8ationProperty Line DISPOSAL PONDS Cl 1 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 District. 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, l shall not employ any person in such manner as to become subject to workman's compensation taws 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 for all required inspect' s Complete dra in 6n reverse si Signed X • — - -� Date: FOR DEPARTMENT USE ONLY Application Accepted by cB 1,L — - Date Area Pit or Grout Inspection by Date Final Inspection by Date _�!�_ t Additional Comments: ElStk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO C H a� C � ou ll +.EH 13-21(REV,i i e 30/1 f 5l "7 0 0. -- EH 14-26