88-608 - 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. t ` Job Address iWY City Lot Size PM ! 1 a67, ` p Ar- oo � 4A Phone (91e Owner's Name �R C�� Address— 95�t3 ` _1�� S Address P &J .6"0 Sit^ License No. J�del j Phone W!�Il 1 Contractor LfL TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL . � OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing j El Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications F] Public 17 Other ❑ Delta Depth of Grout Seal Type of Grout — .I i Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by _ d 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 I I REPAIRlADDITION X� DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units:��r 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 i LEACHING LINE ❑ No. & Length of linesI r Total length/size i FILTER BED El Distance to nearest: Well..A_ Foundation' JD __ Property Line /B SEEPAGE PITS I Depth o115 t _Size— � Number SUMPS 0 Distance to nearest: Well UXLfi— Foundation 301 Property Line 45- 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 J 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 ^ i 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 for all re it inspections. Complete drawing on reverse side. /� g Signed X Title: 60 '1t1cv+ Data: FOR DEPARTMENT USE ONLY Application Accepted by rb4 Date � ) Area or Grout Inspection by T — / - Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca :823-7104 ❑ Tracy 835- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. ' INFO OAS,, / ♦ EH 13-241REV. r/n51 1166 �!J Wv VU EH 14-26 vv I �