88-1245 - Laserfiche WebLink

Home Browse Search

j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) �0&d,orz /9' 7 7 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 weupump and the Rules and Regulations oft the San Joaquin Local Health District. r /r Job Address Cit> Lot Size -'r PM OwnerAddress Q Phone 's Name J Contractor 1rZJ Address License No. Phone-x TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 CONSTRUCTA SPECIFICATIONS " ❑ Industrial ❑ Open Bottom ❑ Manteca Dia-of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ TracyType of Casing - Specifications FI Public 1-1 Other n Delta r4 Depth.of-Grout Seal Type of Grout — I 1 Irrigation _-Approx.�Deptfi t 1 Eastern= Surface Seal Installed by Repair Work Done ❑ Type of.Purnp H.P. State Work Done Well Destruction ❑ .Wel Diameter �" Sealing Material atop 50'1 .� fT r Depth -""�� Filler Material {Below 501 TYPE.OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION i I DESTRUCTION i I availabeti systemithin emitted if public sewer is N .F Installation.will'serve: Residence Commercial— Other Number of living units: /_ Number of bedrooms �� Character of soil to a depth of 3 feet: r Water Sable depth SEPTIC TANK 0� Type/MfgCapacity No. Compartments ` PKG. TREATMENT PLT. ❑ " Method of Disposal ` Distance to nearest: Well a� Foundation � Property Line IM ' r LEACHING LINE No. 8 Length of lines - Total length/size � FILTER BED ❑ Distance to nearest: Wel! de, Foundation ! Property Line' l00 SEEPAGE PITS I I Dep... -(9J Number >6 SUMPS Ll Distance ton rest: Wel Foundation Property Line L4 IQ DISPOSAL PONDS ❑ t 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. I 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 est call for all;equi Complete drawing on reverse side. _ Qy� _ i Title: "Date: i Signed X FOR DEPA TMENT USE ONLY Application Accepted by e ` r F Pit or Grout Inspection by Date Final spection by Date �� 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 FEE AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT NO. INFO _ ♦.EH 13-241REV.1/Hs1i. L V'" �, %U .. C_¢rT.!"� (�!6� '�' a re—�2y EH 14-26