88-727 - Laserfiche WebLink

Home Browse Search

Y f , APPLICATION FOR PERMIT r, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091.466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F (Complete in Triplicate) Application is hereby made to the Sah'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. krr�� - Cit Lat Size PM Job Address l�Cc� �� Y Owner's Name 6E h Y+ J A.M'-so 0 Address as!7b - L) `!� I Q) AD Phone Contract6r" � m��i `� ddress �� 9—mi License No.&L__�tl Phone TYPE OF WELL/PUMP: NEW WELL C_4—/ WELL REPLACEMENT ❑ - DESTRUCTION ❑ PUMP INSTALLATION LY SYSTEM REPAIR Q OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK '�PSEWER LINES _ LQ DISPOSAL FLD,��.`AJJa� �Jp �i)P. LINE ' � qq rte. cx_ FOUNDATION,_ P_AGRICULTURE.WELL, ,.�C7k]CTHER WELLNQ��!c ..PITS/SUMPS hJQ�;, -- - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Mantecaf Dia. of Well Excavation Dia. of Well Casing LJ'Domestic/Private ❑ Gravett � ---+-Pack—0 Tracy Type of Casing;- ��lr? t- i l"1 Public �(� [I Other*� ❑ Delta Depth of Grout Seal Type of Grout _ XIrrigation W10- —Approx. De th I 1 Eastern Surf a a Seal installed by _ .Repair Work Done Lxf�Type of Pump H.P. State Work Done_ r. Well Destruction !❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 -REPAIR/ADDITION l I DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.I J Installation will serve: Residence. Commercial_ Other Q Number of living units: Number of bedrooms r Character of soil to a depth_ of 3 feet: Water table depth SEPTIC TANK. Cl Type/ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LI NE. ❑ No. & Length of lines Total length/size r ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line p SEEPAGE_ PITS I 1 Depth Size Number k i SUMPS ❑ Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ ' F I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sta71aws, 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 issuel not employ anyperson in such manneras to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractng sgnature certifies the following: "I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- tion laws of California." "f t The applican st call for all re red ins c ions. Complete awing or, reverse side. w Signed X Title- L!,iC Date: OR DEPARTMENT USE ONLY Application Accepted by Date _� � Area Pit or Grout Inspection by Date Final Inspection by T/j d11/!! Date / !j �. Additional Comments: - 1 /9 ❑ Stk 466-6781 ❑ Lod 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 HE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT-NO. + EH 13-24(REV.I/H 51 EH 14-28