88-1324 - Laserfiche WebLink

Home Browse Search

- � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t'>('t 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) _ yr'33 /b Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w r hte n des*bX This app) t fs made in compliance with San Joaquin County Qrdinanceh No.549 f r sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I� Jab Address City G' of Size PM Owner's Narrm ,MQ_ f- T ,I�. a ¢ Address / / e_r�ai �/�v Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: i NEW WELL ❑ " WELL REPLACEMENT'❑ ` DESTRUCTION ❑ SIJ fPINSTALLATION-'L1 "" "` -SYSTEM'REPAIR'❑""""`� """""'OTHER"❑'--' - ' ;i DIST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATI AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AR STRUCTION SPECI ` ❑ Industrial 0 Open Bottom ❑ Mantec . o e tion Dia. of Well Casing .i. ❑ Domestic/Private ❑ Gravel Pa Tracy Type of Casing Specifications Fl Public ``t er Cl Delta Depth of Grout Seat Type of Grout _ I I Irrigatio - Approx. Depth I I Eastern Surface Seal Installed by °�. Repair or Done ❑ Typ of Pump H.P. State Work Done_ Well Destruction ❑ Welll Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCT No septic system permitted if public sewer is �I. available within 200 feet.) Installation will serve: Residence_ Commercial_____ Other r'Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ,I SEPTIC TANK ❑. Type/Mfg„ _ Capacity No, Compartments PKG. TREATMENT PLT. © Method of Disposal i Distance to nearest: Well Foundation Property.Line [ LEACHING LINE ❑ No. & Length of linesTotal length/size FILTER 13ED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS} ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IM 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, an 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 taws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify1that 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 r5pst call for all F quireddiinspections. _Complete drawing on reverse side. p Signed X ' 1�_GO/ Title: II FOR DEPARTMENT USE ONLY Application Accepted by l Date �� Area Pit or Grout Inspect i y �� Date Final Inspection'by Date Vchfl Additional Comments: ' :I h-+� l� '1;, be ❑ Stk 1466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 Q Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 \{ INFOME AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. +.EH13-24(REV.,/e 51 S EH 14,26 I� 3S c,