88-2353 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT I° SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. , D f IlJob Address City 1 Lot Size PM E' i.1 Owner's Name Address Phone ?Contractor �•, SS Address`' or License No.30-7 IrS Ph0r1e3 ,;TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ? PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /afd SEWER LINES DISPOSAL FLD.L_S O PROP. LINE ,i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO 1S e/ ;%Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public - 11 Other F1 Delta Depth of Grout Seal Type of Grout CCMI ttl_r 1 i Irrigation /0%4a_Approx. Depth [ 1 Eastern Surface Seal Installed by /V TxIT�`�7i _ Repair Work Done ❑ Type of Pump H. -I. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top SO') Depth Filler Material (Below 50') :TYPE OF SEPTIC WORK: NEW INSTALLATION l IREPAIRIADDITION I 1 DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) 'l Ins allation will serve: Residence Commercial— Other Numbr of living units: Number of bedrooms E Character of soil to a depth of'3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. F) Method of Disposal Distance to nearest: Well Foundation Property Line -LEACHING LINE ❑ No. & Length of lines Total length/size - i FILTER BED LJDistance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. 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, 1 shall not—.- 4 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 applicant mus call f r all quired inspections. Complete drawing on reverse side. Signed X i!►fT3►. Title: 0!!CAn�:. Date: 9'—/, _drd .1 FOR DEPARTMENT USE ONLY a '` Application Accepted by Date ®�,. Area Pit or Grout Inspection by Date 6 00 Final Inspection by Date A0_/.7_JW Additional 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 E FEE INFO AMOUNT DUE AMOUNT REMITTED O H RECEIVED BY DATE PERMIT'NO. + EH 13-24 1REV.1/H 5) \0� 1 f'�� e {� /,/'} Q�.� a-j/� W a EH 14-26 1 0! 5_ 1� t r L / ' I