88-1086 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT L� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ® 996Z ii�,� '� Telephone (209) 466-6781 .AF�� .yLti PERMIT EXPIRES 1-YEAR FROM DATE ISSUED /s q NV Np F , M ER (Complete in Triplicate) � �0 Application is, to the San Joaquin Local Health District for a permit to construct and/or install the work herein descr�if..This application is 1 made in complianc�e',T?1111Bpn 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. /Y. Job Address r f�� d /t' 1 "�l �� city�K 'ILot Size PM Owner's Name6,' /, & � /� r°/" Address �`�`�� u� /' /\CL• Phone Contr.aclor"41 �_ 1E,e Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION- r 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 (} Public Cl Other 17 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REPAIR/ADDITION kr DESTRUCTION I I (No septic system permitted if public sewer is -" available within 200 feet.] Installation will serve: Residence Commercial-k- Other Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK IR' Type/Mfg x 6DnC1l Capacity ) , No. Compartments 'E PKG. TREATMENT PLT. ❑ PC f A nk Method of Disposal G Distance to nearest: Well Q f Foundation k Property.Line x LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' i SEEPAGE PITS I 1 Depth Size Number t`d SUMPS LI'� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Q � - _ 1 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 Healih 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 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 applic ust call r all required inspections. Complete drawing rave a side. Signed Y Title, . Date: X� FOR DEPARTMENT USE ONLY 4 Application Accepted by Date J Area Pit or Grout Inspection by Date Final Inspection by Date -- ;= Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 .Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FEE 41 INFO lyAMOUN/T,rJ�DUE AMOUNT REMITTED ASR p RECEIVED 9Y DATE PERMf T�'NjO. k s,EH 13-24 IREV,i i H sf NF1 � �It) +' �q.! {, a �t �!�(J EH 14-26 11�� V