88-806 - Laserfiche WebLink

Home Browse Search

1 APPLICATION FOR PERMIT q I14 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ►'1 PERMIT EXPIRES TYEAR 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. 11362 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / Job Address Z2077 yj k A 62 City Lot Size PM I � Owner's Name ddress Phone Conti actor Aagelw4vs Address License No. Phone ` 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR`� i OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES !DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS M INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑_Open Bottom ❑ Manteca Dia. of Well Excavation I Dia. of Well CasingCS t MPDomesticl Private ❑ Gravel Pack ❑ Tracy - Type of Casing 4 Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation —Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ElType of Pump H.P. State Work Done � -�CE � �. e.T// `J i Well Destruction ❑ Well Diameter Sealing Material (top 501 /IJJC-J� rjNd;7� Depth _ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i-I DESTRUCTION l I (No'septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— Commercial_ Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity .� '` f No. Compartments F PKG, TREATMENT PLT. ❑ ` Method of Disposal Distance to nearest: Well Foundation ,r Property Line ` LEACHING LINE ❑ No. & LengtWof lines Total length/size ? '( FILTER BED ❑ Distance to nearest: Well Foundation �k Property Line � SEEPAGE PITS I I Depth Siie ```_ ^ . `' '• ' �_ Number SUMPS ❑ Distance to nearesti',,,i Well Foundation Property Line p DISPOSAL PONDS ❑ 1 � t 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. r ,:! 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." ;i l The applicant II grI require in ctions. Complete-drawing.on..revers _side.- i Signed X ' title: _ Date: T FOWDEPARTf1RENT USE ONLY ! •�'t, r Application Accepted by �--`� 'Z k' Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-67$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton{Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIVNO. INFO [yJ CA,$H 1. t EH 13-24(REV.i l m 5) EH 11-26 t-G'-