88-627 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT ,1 1601 E. HAZEL T ON AVE., STOCKTON, CA t Telephone (209)466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) VLR M�tvT HE T Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor e[e#L� e ,crib ica i n is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weillpump and the Rule [i 4�Y11fa4irS� Joaquin Local Health District. , Job Address(O � City Lot Size PM Owner's Namo Address-3412, Phone Contract Address LLiicense No# Phonea� —_� p TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ q,11-.- : PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "z FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS 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 r M Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation _--Approx. Depth I Eastern Surface Seal Installed by F ems, _ Repair Work Done ❑ Type of Pump H.P. L17� State Work Done �=,at 7 Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBelow.501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence� Commercial— Other 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. ❑ r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines :Total length/siie - FILTER BED LJ Distance to nearest: Well Foundation — . Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ 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 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X --- Title: ' Date: R DEPOPTNIENT USE ONLY Application Accepted by Date r a Pit or Grout Inspection by Date Final Inspection by Date �7�V ` Additional Comments: f ❑ 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 95:201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.tR5) 91071 EH 1426 �f