88-618 - Laserfiche WebLink

Home Browse Search

r t x APPLICATION FOR PERMIT y � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.- HAZEL T ON AVE., STOCKTON, CA 1G "C •Telephone 12091 466-6781 ► PERMIT EXPIRES 1 YEAR FROM DATE ISSUED2�c' (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he in described. An is made-in compliance with San Joaquin County Ordinance No 549 for sewage or No. 1862 for well/pump and the Rules and ROg"yl8t'i tit a�n Joaquin Local Health blstnct' 7� ,:� sr l v 1'k .'� F m' 4-l l�vll``�t`` r [� ) � Job'Address r9�a �� .t:✓G�� 'T` i City / Lot Size PM _t /'s Name ��fOwnerAddress Phone Contractor Address ".Aofah, fiAz icense Na. I5 Phone .TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK _. � } r SEWER LINES DISPOSAL FLD.,01+PROP. LINE _-FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r! ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation n'f Dia. of Well Casing j$( Domestic/Private (Gravel Pack k(Tracy Type of Casing NB .2 Specifications F] Public ❑ Other Cl Delta Depth of Grout Seal Ty a of Grout ! I Irrigation _.Approx. Depth l 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 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER i BED ❑ Distance to nearest: Well Foundation Property kine SEEPAGE PITS I I Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line ' ' 'DISPOSAL PONDS –❑ �-- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin counly.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." Contractors 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 app tca must call for all re ed inspecti s. Compla rawing o averse side. Signed X /f Title: Date: fi DEPARTMENT USE NLY Application Accepted by �� Date Area Pit or Grout Inspection by Date /�/ Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED CK INFO ASH RECEIVED BY DATE PERMIT'NO. �j /� ///��(Cg ��iii /J :7 (� + EH 14-24IREV,I. r /a 11v J� // F �r Vf- �