88-2319 - 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 E��A►- H ES PERMIT EXPIRES T YEAR FROM DATE ISSUED E M1� (Complete in Triplicate) F 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. 7 � 9E �YA- City �f/Vb�15/Lot Size PM Job Address Owner f 1 �� ddress Phone 's Name �0 S No.�—Phone Contractor S Address License DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL LJ vv— .—EPLACEMENT ❑ PUMP INSTALLATION 11 SYSTEM REPAIR OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS m INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI N SPECIFICATIONS`""�` ` W "F El industrial 1-1 Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ]Domestic/Private ❑ Gravel Pack ❑ Tr�,�_�_� Type of Casings~.� Specifications ❑ Public ❑ Other �^ C1 DeIt I . Depth of Grout Seal 1 Type of Grout Approx. D pth •Rastailed - ` I I Irrigation � � tem 5t�riaca Seal In lby t{ �. ��3 State Wofk Done Repair Work Done ❑ Type of Pump 1_,L�C _ H.P. j � a � Y Well Destruction ❑ Well Diameter Sealing mate«I t p 50' Depth Filler MeFial'IBe 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 R[.PA^R/!>DDfrfON l I DESTRUCTION [EI (No septic system permitted if public sewer is 7� available within 200 feet.) Installation will serve: Residence_ Comme al 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 CI No. & Length of linesy Total length/size FILTER BED ❑ "Distance to nearest: ! Well Foundation Property Line l SEEPAGE PITS I I Depth V Size Number SUMPS ❑ ' Distance to nearest: Well Foundation Property Line — DISPOSAL PONDS ❑ _- 11 - --. . -..... I hereby certify that I have prepared this application and that the work will be done in accordance with San J�o�q'yin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health`District. Home owner or licensed agent's signature certifies the iollowin� '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 subjeA to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance f the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant 114"or l require c' ns- Co plate dewing on rev sa side. 7 rQ Date: C Signed X )� Title: f0 , P fMENT USE ONLY Application Accepted by _ Date �` Araa Date P-Z I- ( � Pit or Grout Inspection by �`- 1 - 'Date Final Inspection by Additional Comments: 1 .._ -..__❑-Stir'-4fi6=&781 -❑"Lodi"3G9=3621—❑'-Man ace 8237T04-""—Q" rT'any 835"6385---^-- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 v v: FEE AMOUNT DUE AMOUNT REMiTTE6' CASH\ RECEIVED 6Y DATE PERMIT NO. o- INFO +.EH13-241REV,1/H5) EH 14-2e