88-3019 (2) - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1"YEAR FROM DATE ISSUED I (Complete in Triplicate) r 1 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 Rules and Regulations of the San Joaquin F Local Health District. r I Jab Address � �( `! City Lot Size Zea PM i # 4a Ole Address Phone Owner's Name Contractor Address_ license No. Phone_ E TYPE OF WELL/PUMP: j NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION >I (� PUMP INStALLATION ❑ 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 L1 Industrial ❑ OpedBottom ❑ Manteca Dia..,of Well Excavation Dia. of Well Casing ❑ Domestic/Private 1-1 Gravel Pack ❑ Tracy Type of Casing Specifications 7 Public Cl Other Ll Delta Depth of Grout Seal Type of Grout—.-- II rout _II Irrigation Approx.-Depth I I Eastern Surface Seal Installed by a �- L Repair Work Done ❑ Type of Pump H.P. State Work Done_ S 1111 Well Destruction Well Diameter Sealing Material (top 50'1 Depth 3 Filler Material l8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION t 1 DESTRUCTION l i INo septic system permitted it public sewer is l available within 200 feet.) k lnsVilation will serve: Residence " Commercial_ Other f Number of living units: Number of bedrooms - - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl- No. &.Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth} Size Number SUMPS I_1 Distance to nearest: Well - Foundation Property Line DISPOSAL PONDS ❑ + _ -;" r 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, I shall not employ any person in such manner as io 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" A compensa- tion laws of California. r �' a The applicant ust call for all required inspections. Complete drawing on reverse side. Title: Date: ll� l .- /I e Signed X lewn,A-1 FOR DEPARTMENT USE ONLY t Date I Area_ Y Application Accepted by Pit or'Grout Inspection by Date' - Final.InspLIZ ection by Date . v ! 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."Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .j FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT INFO j :;;"I'D Ell13-24(REV.t�n51 �/ FH 14-2e ., _