88-2718 - Laserfiche WebLink

Home Browse Search

r �I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT LLLJJI 1601 E. HAZEL T ON AVE., STOCKTON, CA OCT 1 11988 r, Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUEDIAEALTH L=*,1 it: idFvl �37f�t I (Complete in Triplicate) 4'ERhJi=l SEi��ILES 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 s Local Health District. Job AddresCity Lot Size PM .i ld- Owner's Name Address Phone + Contractors - _- Address&/ Ila nse No Phon es - i 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 1-1 Other C7 Delta Depth of Grout Seal ,Type of Grout _ f I Irrigation _IIApprox. Depth I 1 Eastern Surface Seal Installed by - ; Repair Work Done ❑ Type of Pump H.P. State Work Dan _ r Well Destruction EJ WeII+Diameter Sealing Material (top 501 Depth Filler Material I6elow 50') TYPEOF SEPTIC WORK: NEW INSTALLATION !_l REPAIR/ADDITION 1.1 DESTRUCTION 1 1 (No septic system permitted if public sewer is 11. available within 200 feet.l Installation will serve: Residencet_: Commercial_,,Other' j 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 LEACHING LINE ❑ No. & Length of lines Total length/size - -- FILTER BED ❑ Distance to nearest: Well Foundation Property Line I� SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Il 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 i rules and regulations of the Sar(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 i 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." ii The applicant must I for all r uir d i spections. Complete drawing on reverse side. Signe - Title: Date: It. FOR DEPARTMENT USE ONLY / ! Application Accepted by " Date ` f a' Area O it Pit or (Grout Inspection by il Date Final Inspection by Date !!3 Additidnal Comments: ! ❑ Stk 466-6781 ❑ Lodi 11369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applic nt - Return all copies to:,Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY yy DATE PERMIT'NO. *.EH 13-24 4REV.1/85k 0 ] �9H— �EH 14-29 ; g. W7y I�