88-2866 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 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, } i Job Address zi/ Qty �' V� ®11 yToojk y�w -� �`� Uty r`- of Size PM Owner's Name `�� Address Phone Contractor�r, �- �'v Address License No. Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER )1� 071 FOUNDATION DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t1 M Public n Other F] Delta Depth of Grout Seal Type of Grout I I Irrigation �_.Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Stale Work Done Well Destruction ❑ Well Diameter -.- Sealing Material (top 50') X&kL " r 'ea �`�& t'at9 Depth Filler Material Ieelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I 1 DESTRUCTION I I INo'septic system permitted if public sewer is 141, i Installation will serve: Residence Commercial available within 200 feet.) _ Other ; Number of living units: Number of bedrooms Character of sol to a depth of 3 feet: Water table depth SEPTIC TANK fD Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.. i ` Method of Disposal ..—I Distance to nearest: Well Foundation Property Line LEACHING LINE ) CI No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r r SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS Property Line r El �• 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. 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Calif The applicant st I f I re inspections. Complete drawing on reverse side. g Si ned Title: J�4L- (/''�� ! s ;/` Data: FOR DEPARTMENT USE ONLY Application Accepted by Pit c�r�raui Inspection by bate K9 Inspection`by y Date. v Additional Comments: ❑ Stk 466-6781 _0 Lodi 369 3621 ❑ Manteca 823-71 ❑ Tracy~ 5-6385 Applicant/)Retum all copies to: En ironme ati�Permit/Services I6S}1 E. H dalton Av�.�p.0, Box 2009, Stk- A yrt201 FEE AMOUNT DUEAMOUNT REMITTED CK INFO CASH RECEIVED 13Y' DOTE PERMIT'Np. r y +.EHt}24(REV.,in5) '> - `t� -"' EH 14-20 �/� �51f� r