88-496 - Laserfiche WebLink

Home Browse Search

- APPLICATION FOR PERMIT "5 f t. 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District.f s � �,/�,�/� l p�f yUpi7ir�i Job Address f_ fr�l G(llc CD J /lJ City Lot Size tw.S P"M ' I Owner's Name 7Address Phone Contractor 0,5 Address OOS' e No. c2LJOB/'3 Phone ` r/ TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ i 1 PUMP INSTALLATION �� ❑ SYSTEM REPAIR ❑ OTHER '' LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD./ZPROP. LINE FOUNDATION' 4 — 'AGRICULTURE'WELL — OTHER-WELE4�PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private Gravel Pack >f Tracy Type of Casing PSG Specifications C'l Public f 1 Other n Delta Depth of Grout Seal _ �/ Type of Grout � 11�/}� Y` 1 Irrigation f 1S.L__Approx.'Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50 Depth C Filler Material !Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is Q 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. ❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I l Depth 1 Size Number SUMPS-...n „❑ Distance to nearest: -Well _ Foundation n —Property Line — __-q DISPOSAL PONDS ❑ I 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 foil wing: ''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 C lifornia." The app rc t must call_for all r ire, inspections. Co ple a dr ing on rev rse side. /- y�7 Signed X t Date: t ( 71 e 4 r FOR DEPARTMENT USE ONLY t AAlicat i n ccet Date Armnspection by bate Final Inspection by R E: �V E D Additional'Comments -dsa 'P f ❑ Stk 4M-6781 C5odi 369 3621 Cl Manteca 823-7104 ❑ fracy 835-6385 ;% � 6--r^B r /�rf7 Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, S tk., CA 95201 ENVIRONMENTAL HEALTH INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMCK A IT p. /ICES + EH119-28 l 3-25(REV EH .I/K5] `7 ►Oo `7a