91-0652 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �PAY ��` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED If e'VED (Complete in Triplicate) SA IIAR ' 9 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install ti,wAwlgt `ta i(; i ication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and t LII��Ti}►�s�r Joaquin Local Health District.. pL HEALTH DMS�� Job Address r`1 �1 1 f' ��f 1 rive, city SLI�JtYIn Lot Size PM f Owner's Name n�{ 1 }� Address S 1�. Sft7 Uf Phone _ZM 1, 0043 co AIC 147— 85-2-5 A\ Contractor XcEI �1f\ Address Fe"on eens!No.C!�;-7— l�s"[� Phone_ l5- TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER MOht -arIn -3 WQlj 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 yy ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation q5; [" Dia. of Well Casing � vtcvh ❑ Domestic/Private XI Gravel Pack ❑ Tracy Type of Casing Fi4so f y(l Specifications I7 Public Cl Other n Delta Depth of Grout Seal Type of Grout e " " I i Irrigation _;Ko Approx.`Depth I I Eastern Surface Seal Installed by rCpAi�y _ Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 50') _ �1 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is ) 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 r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. 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 / SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 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 must call for all required I Complete drawing on reverse side. f Signed X Title: s�-r� -��ds�IS�T� Date: s FOR DEPARTMENT USE ONLY _ Application Accepted by _ �1 Date J Area Pit or Grout Inspection by, Date 'o L__��_ _ Final Inspection by � �X LF-Y, Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazellon Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY HATE PERMIT'NO, +.EH1144-2e-241REV EH .t/H5) '(yl ©h t/}�1 Lf S I Iq[ M 1 {