88-3065 - 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/of install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for--welllrpump and the Rules and Regulations of the San Joaquin Local Health District. lob Arlrlrasc 453C,IC.lE >�'A�YL Y U. Citd"now_ Lot Size - '6•1kQ,_ PM Owner's Name i_Jl Address 1 � (00 t `a'r l Phone j Contract `A ddress V0. 02! 1(112 f rLicense No. _Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.- --PROP. LINE r - FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public M Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H, P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material'(Below'50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ ADDITION 1 1 DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence f! Commercial _ Other Number of living units: —I— Number a e rooms Character of soil to a depth of 3 feet: Water table depth 00-1 SEPTIC TANK * Type/Mfg Capacity -(Q-0-0— No. Compartments PKG. TREATMENT PLT. ❑ i f Method of Disposal Distance to nearest: Well . Foundation Property Line_ I � LEACHING LINE X No. & Length of lines Total length/size Q FILTER BED ❑ Distance to nearest: Well Foundation Property Line Jr SEEPAGE PITS lR Depth �]iJ� Size _ �� T_ Number SUMPS Ll Distance to nearest: Well 00.Foundation 16 r Property Line ' DISPOSAL PONDS ❑ 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 folldwingy' 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." Theapplicant st ca11 for Ire fired inspections. Complete drawing on reverse side. QQ Signed X Title: � R Date: FOR DEPARTMENT -USE ONLY ` /A'p�plication Accepted by �c.� Area / Pjt or Grout Inspection by � Date )/ Final Inspection by Date % /Additional Comments: - ❑ Stk 466-6781 ❑.Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 +.EH 13-241REV. iia5) EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. a k` r7 ! &K 30 L1 f LV Irl