88-2250 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 f%(oQ�r w�► PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) e rt 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 City tot Size PM Owner's Name 1Ye Address '(0 h'al Ale— one Contractor Address License Na. Phone _ - TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEME NT, ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ry DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESISPOSAL FLD. PROP. LINE . FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPr, INTENDED USE ❑ Industrial ❑ Domestic/Private i-1 Public I I Irrigation Repair Work Dane Well Destruction TYPE OF WELL ;,NROBLEM AREA ONSTRUCTION SPECIFICATIONS 10:1Open Bottom s antec Dia. of Well Excavation ❑ Gravel Pack ❑ Type of Casing r ❑ Other Delta n Depth of Grout Seal t ' _.-Approx. D ❑ Type of Pu ❑ Well Di meter T ea ngatenal Itop 50) t Depth ' T Filler Material (Below 50') _ f TYPE OF SEPTIC WORK: NEW INSTALLATION 11 RLPAIR/ADDITION I 1 DESTRU Installation will serve: Residence Commercial — Other Number of living units: — -Number of bedrooms Character of soil to a depth of 3 feet: i l Eastern Surface Seal Installed by H • R. State Work pone _ 5 I" M ` SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Distance to nearest: ;r Well LEACHING LINE ❑ No. & Length of lines FILTER BED r Dia. of Well Casing Specifications Type of Grout 1No septic system permitted if public sewer is available within 200 feet.) Water table depth Capacity No. Compartments t Method of Disposal - Foundation Property Line Total length/size ❑ Distance to nearest: Well Foundation Property Line C r f SEEPAGE PITS 1 1, Depth Size Number SUMPS Cl Distance to nearest: - Well Foundation Property Line � DISPOSAL PONDS ❑ O 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 nat 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 applicaU must call for all raouired i=rn rtinne Co I t d Signed Application Accepted by Pit or Grout Inspection by mp e e raw ng on reverse side. < Title: Date RTMENT USE ONLY Date _ Final Inspection by �u ti lrea / �– Date �/ lQ (X1 Additional Comments: kn ❑ 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 +.EH 13-24 (REV. 1/ a 6) EH 14-26 INFO FEE AMOUNT DUE I AMOUNT REMITTED DK RECEIVED BY '3� � 35.c.15 I3R0 A4�✓S DATE PERMIT' NO. M 1 42 ldy-mss©I