88-1507 - Laserfiche WebLink

Home Browse Search

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 (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 2 15-110 City Lot Size PM Owner's NameYGM-LAddress 1 ��- �� hone v Contractor Address License No. Phone i TYPE OF WELL/PUMP: NEW WELL d;�-- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ems' _ 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom a El Manteca Dia. of Well Excavatior� Dia. of Well Casing I 1160mestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications . Irl Public [-1 Other 171 Delta Depth of Grout Seal J�r Type of Grout I I Irrigation Approx. Depth l 1 Eastern Surface Seal installed by Repair Work Done ❑?t Type'pf Pump' H.P. State Work Done_ Well Destruction ❑ Well Diameter ''. Sealing Material Itop 501 Depth Filler Material-(-Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONIJ, REPAIR/�ADDITION.i-]..'DESTRUCTION i I (No septic system permitted if public sewer is ` � available within 200 feet.I �J Installation will serve: Residence— Commercial.— -Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f' _- Water table depth w SEPTIC TANK 0--Type/Mfg -Capacity No. Compartments PKG. TREATMENT PLT. ❑ T.; Method of Disposal Distance to nearest:- Well Foundation Propeny.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:w Well `�-Foundation-- _. ---- Property-Line' W SEEPAGE PITS I I Depth Size 'f �` 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 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 n 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 c I for all requir d ins pe tions. Complete drawing on reverse side. I Signed Title: r Date: ~ ! FOR DEPARTMENT USE ONLY f Application Accepted by / Date G ^ Area Pit or Grout Inspection Date �( � F I Inspect in by Date/10—A _� Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 623-7104 L ❑ 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 REMITTEDC H RECEIVED BY DATE PERMIT"NO. C_ EH 13-24 INFO 24[REV.tiH51 LS S ��-Ems EH 14-2B