88-2040 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i 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/or install the work herein described.This application is made in compliance with a Joauio i ce S"�r 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 Nameki I4Address s � � Phone 1 Contractor's Name C Ligense No. 37IS6& Phone TYPE OF WELL/PUMP: NEW WEL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ QDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL- PITS/SUMPS O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFJJtATJ5Zf 11' i ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing D estic/Private C.1JJXvraVefPack LJ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal f 1 Type of Grout [ /J ❑ Irrigation Approx. Depthj'as'f!ern Surface Seal Installed by Z Repair Work Done ❑ Type of Pump W.P. State Work Done m U Well Destruction ❑ Well Diameter Sealing Material (top 50') I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 1 ✓ Number of living units: Number of bedrooms el Character of soil to a depth of 3 feet: Water table depth Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments S kA PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lineae LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 cMertfffy 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 ust l for l t ire in pec ns. Complete drawing on revers side,., s Signed X Title: Date: L FOR DEPARTMENT USE ONLY / yU, Application Accepted by C Date /Q Area Pit or Grout Inspection by ' Date r/(ASFinal Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY I DATE PERMIT NO. + EH 1324{REV. 10/831 �� 1.6 EH 14-26 GLL /'t!