88-677 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephoner(209)"466-6781 PERMIT EXPIRES tYEAR 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. Job Address __-1- /L`GL it 7j _E City s� Lot Size PM Owner's Name Address .5Z?j L Phone e_ 6 Contractor Address License No� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 SPECIFICA ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wellion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack EJ-Tracy _ - -T Casing-=� -- � Specifications M Public w n Other F1 Delta Depth of Grout Seal Type of Grout _ I Irrigation _.Approxi Depth I.1 ern Surface Seal Installed by _ Repair Work-Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diartt� Sealing Material (top 501 DepthI Filler Material lBelow 50') _ TYPE OF SEPTIC WORK:. ;NEW IN I ] REPAIRIADDITION 11.xw DESTRUCTIO (No septic system permitted if public sewer is f�^ vailable within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: t. Number of bedrooms Character-of soil to a depth of 3 feet�. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments L PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:, Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines /Total Total length/size S FILTER BED ❑ Distance to nearest: Well Foundation 1 `Property Line i SEEPAGE PITS I I Depth I Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - --* I hereby certify that 1-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 Di§trict. 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 m t call for all required 'p spe ions. Complete drawing on rev a side...T _ F _s Signed X ;R0 Title: i FOR DEPARTMENT USE ONLY C Application Accepted by : { Date " Area ZJ Pit or Grout Inspec#i` Date Final Inspection by DateLt Additional Comments: t') 0 ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 _ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE INFO AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 01 EV, EH 14-28 ✓ - �� / V7�