88-478 - Laserfiche WebLink

Home Browse Search

' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone {209) 466-6781 apt�7 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) l 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 Address / /�- d/D4OJ� City Lot Size )c `a� �� PM Owner's Name �' Address /�/ /"• /H/��/-�� Phone gkd Address �}� iitA�i� License No. Phone Contractor�� i !rJy � /�/ ��-. klpv ' TYPE OF WELL/PUMP: "NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L1 SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '"1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing � k ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('l Public ❑ Other Cl kDelta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth { 1 Eastern Surface Seal Installed by _ Repair Work Done C) Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth I Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1-1 DESTRUCTION I No septic system permitted it public sewer-is ilable within 200 feet.} Installation will serve: Residence Commercial_ Other ty��l, �1.�3�� 0��,� Number of living units: Number of bedrooms k f k— Character of soil to a depth of 3 feet!: Water table depth ' i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance fto nearest: Well Foundation Property Line SEEPAGE PITS E 1 Depth I Size Number SUMPS ❑ Distance�to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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, I shall not y employ any person in such manner as to' become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifiesthe Ilowing: "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 alifornia." $[ The applica m t all f required inspections. Complete drawing o ae�rse side. I Signed X Title: Q• X6riA1 -TD1tp Date: FOR DEPARTMENT USE ONLY i Application Accepted by ODate 3~ `' V- Area Pit or Grout Inspection by Date Final inspection by �' Date ?�Ja Additional Comments: / SG A2 2 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE! AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. 3.57 0 _�.r 67d2/ �-�8 -f7� +.EH 13-21[REV.t i N 5t g_` EH 11-28