88-1002 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601.E. HAZE10ON AVE., STOCKTON, CA Telephone (209) 466-6781 x.r .H - • I PERMIT EXPIRES 'I 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 in the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for"I/pump and the Rules and Regulations of the San Joaquin Local Health District. A, CO- } C,ty :�U f Lot Size PM Job Address ,_ � ,.. .' "- Phone Owner's Name e(/.2: P GAddress Contractor (' f Address License No Phone TYPE OF WELL/PUMP: . NEW WELL ❑ WELL REPLACEMENT El , ,mss DESTRUCTION S❑ 4" «.--•---�- -PUMP INSTALLATION-❑ ---- "`"""`SYSTEM REPAIR'❑�"" `'OTHER ❑`�" "�' '"�""tet �� _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'k INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ElIndustrial Q Open Bottom E3Manteca Dia. of Well Excavation Dia. of Well Casing El7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Otlier ElDelta Depth pf-Grout °` Type of Grout ii El Public - i j ❑ Irrigation --J ox. Depth ❑ Eastern Surface Seal Installed. State Work Done Repair Work Done ❑1=F Typepe of Pump ;H.P. ; I Sealing Material {top 50'1 1 Well Destruction ❑ Well Diameter 9 Depth Filler Materiai_IBelow.501 TYPE OF SEPTIC WORK: :NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION-0 (No septic system permitted if public sewer is x ,—available'withiri 200"fe#t'1'" i Installation will serve: Residence 1C_ Commercial Other Number of living units: ;Number of bedrooms- —. �,. W - '"'q t* -� Water table depth Character of soil to a depth-of 3•feet: - ,. nC�Pi`1 �. ry, kT--j"' opacity ; C�f1('1 No. Compartments. - SEPTIC TANK Type/Mfg ? ! +- -:�'-"� *- Method of Dispoal PKG. TREATMENT PLT. ❑ B �- /_ _ ',�.•� �rr�� _.�=— rte! 5 Distance to nearest: '50- Well Foundation Property Line a LEACHING LINE 01."No. & Length'of lines ` '(S Total length/size v FILTER BED ❑ Dista e1to nearest: Well - Foundation--3o Property Line SEEPAGE PITS ❑ Depth Size Number f SUMPS : Q Distance to nearest: Well Foundation Property tine i' 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 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all req 'ed inspections. Complete drawing on reverse side. rG C L .V.A.� Title: ft %4 — Qate: Signed " `: - - - �A DEPARTMENT USE ONLY - ,,,� ! f' � —! Application Accepted by Date Area wDate -7 Ify Pit or Grout Inspection by Date Final inspection by Additional Comments: r ❑ Stk 466-6781 C1 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 fi395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT'NO. FEE INFO AMOUNT DUE AMOUNT REMITTED CASH + EH 13.24 1REV.)/R)/a 5Y �� ✓�� ` EH 14.26