88-859 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA I 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.1.862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. X, laid; r Job Address 7 ,2t% ., '`S �CitY 77 dot Size Owner's Name l A dress S Q Phone 'r Contractor Addressv License fly Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION � SYSTEM REPAIR LJ OTHER C DISTANCE TO NEAREST: SEPTIC TANKS` SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _�� AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Z-BornesticlPrivate WX&rWMl Pack ❑ Tracy Type of Casing _ -iV Specifications Type f Grout I`1 Public F1 Other H Delta Depth of Grout Seal YP — I Irrigation _.Approx. Dept Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump • H.P, State Work Done } Well Destruction ❑ Well Diameter Sealing Material (top 50') r�µ Depth # Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I i INo septic system permitted if public sewer is o available within 200 feet.) " Installation will serve: Residence 4 Commercial_Other G r •' *_n4 Number of living units: Number of bedrooms 11f r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. LI Method of Disposal Distance to nearest: Well Foundation Property Line € i ' I LEACHING UNE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS f I Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 thatn 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 d6rrtxpensatibn`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,1 shall employ persons subject to workman's compensa tion laws of California." # ' s*.J` r The applicant `must call for all required inspect s. Complete drawirig'orS'reverse side. I/-Signed X+�,"� Title: Date: kbA ' FOR DEPARTMENT USE ONLY ] Application Accepted by Data ✓` � v Area r Pit o Inspection by I ate`G 1'2 Final Inspection by Date 4P EAdditional 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 I FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. i S fir- FFS9 r EH-1 -24fREV.tia57 O EH 144-28