87-2177 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT CS SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE;TON AVE., STOCKTON, CA Telephone (209) 466-6781 Ngo y c�n V-LN -, PERMIT EXPIRES TYEAR FROM DATE ISSUED IIII 11 4 (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 e or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin'County Ordinance No. 549 for sewag Local Health District. i � r Il Job Address L { U City Lot Size PM r _ 4Ue— Phone Owner's Name �S� �• � � , ddress r Contractor _S Address t License No. Phone_ TYPE OF WELL/PUMP: JNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 171PUM STALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL FLD. PRO . LINE FOUNDATION GRICULTURE WELL OT PITS/SUMPS M INTENDED USE TYPE OF WELL PROBLEM AREA CTION SPECIFICATIONS _ ❑ Industrial ❑ Open Bottom eca Dia. of cavation Dia. of Well Casing ? ©Domestic/Private ❑ Gravel i El Tracy Type of.Casing Specifications „ I Type of Grout ("1 Public - ther � 1-1 Delta Depth of Grout Seal I Irrigation _--Approx. Depth t 1 Eastern Surface Seal Installed by Repair Done• ❑ Type of PUmp H.P. State Work Done Well Destruction ❑ Well Diameter. Sealing Material (top 501 { Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR)ADDITION Ll DESTRUCTION (No septic system permitted if public sewer is i 1 available within 200 feet.) Installation will serve: Residence'* Commercial_ Other t 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 PKC. TREATMENT PLT. ❑ „; - Method of Disposal Distance to nearest: - Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I : ' SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I h 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 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 st call for all req ' dji �.ons. Completarawing on reverse side. Signed X Title: _ �� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date –� Area IG P7 € Pit or Grout Inspection by Data Final Inspection by Date 9' Additional Comments: 3 ❑ 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 9 RECEIVED BY DATE PER NO. INFO + EH 43.24{REV,I/n 57 EH 14-2d F