88-1005 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe (249) 466-6781 PERMIT EXPIRES TYEAR 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 San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address cex City Lot Size PM /_ I Owner's Name Address* Phone� �+ 7 Contractor: Address License No. Phone � i TYPE OF WELL/PUMP: 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/SU.MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r d ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public (=1 Other C] Delta Depth of Grout Seal Type of Grout _ ti I I Irrigation _.Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ 1 Well Destruction ❑ Well Diameter Sealing Material Itop 501 T Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITIONX DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_X Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: a Water table depth SEPTIC TANK ❑ Type/Mfg Capacity .°Tf.)06 No.-Compartments PKG. TREATMENT PLT. ❑ Method of Disposal � Z� - Distance to nearest: Well � oundation Property Line ,X — LEACHING LINE lit/ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: We c Foundation Property Line 22 SEEPAGE PITS Size I Number SUMPS L] Distance to nearest: Well oundation 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 Di1trict. 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: "1 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 st ca fo II.requir inspe io s. Complete a ing on revers ide, r Signed itle: �� `�� h Date: FOR DEPARTMENT USE ONLY Application Accepted by f g1 A _ Date 01.�' Area �- d f' r rout Inspection by Date /WFinal Inspection by //1 / f Date Ad ions tfhents: "ell( ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO 13-241REV. /nsl /��/"� E //�� /7f�� ♦. t{ 0 c) V%J _9 ',�"" '-✓�"" EH 14-26 /// V "f''