88-691 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA + Telephone (209) 466-6781 f PERMIT EXPIRES 1"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. Job Addresst 1�� F. _ City Lot Size CICjiSAL) PM F - } Owner's NamPO� AAddress t � ►tt�� RA. Phone Contract �tl Address ■�. [t�7 r/��"` r License No. Z�Zz�' Phone 3( _10S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f ...� W PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Y DISTANCE TO NEAREST: SEPTIC TANK T _ SEWER LINES DISPOSAL FED. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 2—�', --,-- 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 f`i 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 ❑ Type of3Fump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ler Material (Bel m 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 EPAIR ADDITION. DESTRUCTION I 1 lNo septic system permitted if public sewer is 0^ te t, available within 200 feet.) --} Installation will serve: Residence ��Commercial_ Other Number of living units: /- Number of arooms tt f ' Character of.soil.to a depth of 3 feet: . �1 _.._....__...__ ____... _ Water-table-depth.^_)_ �"--–---.-- - -- .. SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Qh_ Distance to nearest: Well —,Foundation Property Line LEACHING LINE ❑ No. & Length of lines-, Total lengih/size { r_ FILTER BED ❑ Distance to nearest: ,Well Foundation Property Line. SEEPAGE PITS X Depth }Size��L� '�T Number _ SUMPS L� Distance to nearest: Well_-,�-00 Foundation %0 Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will'be done in accordance with $an 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 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 applicant m t call far=uiredpections. Complete.drawing on reverse side. ' o r Signed X / Title: L 1 Date: FOR DEPARTMENT USE ONLY F G (�� Application Accepted by In � �y Date r`� k_d V d Area) 1 Z 1 r.Grout Inspection by Af Date;=7`'Z ��o Final Inspection by�IZ�Y/+/A`'T,r, -6s�'-u .Date' - . Additional Comments-, ❑ Stk 466-6761 C7 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE A OUNT REMITTED ASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.�/n 51N66 EH t4-2ti '