88-1555 - Laserfiche WebLink

Home Browse Search

K APPLICATION FOR PERMIT 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (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. I� Job Address / � Lf�! � ___-- City, Lot Size PM Owner's Name Address L0904) / ��r�t.� e Phone' 1 ConiractAAC' r 3 �f Address License No 2O 7— --Phone.- -�p��rl TYPE OF WELL/PUMP: il: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ N, ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, DISPOSAL FLD. "PROP. LINE FOUNDATION AGRICULTURE.WELL OTHER;WELL PITS/SUMPS i i, INTENDED USE_ ... TYP,E OF WELL PROBLEM AREA CONSTRUCFIONASPECIFICATIONS f ❑ Industrial ❑ Open Bottom LJManteca Dia. of.Well Excavation Dia. of Well Casing 171 Domestic/Private ❑ Gravel Pack ❑ Tracy '"^`-- Type'of Casing Specifications fl .Public ❑ OtFier ❑ Delta Depth of�Grout Seal Type of Grout I 1 Irrigation —Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State-Work.Done Well Destruction ❑ Well Diameter Suring Material (top 501 Depth ` .� filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION (1 .•REPAI ADDITION L DESTRUCTION I 1 '(No septic system permitted if public sewer is yI' , available-within 200 feet.) Installation will serve: Residence Commereial� Other `- " _ A Number of living units: �!t Number of be roo � I f Character of soil to a depth of i3 feet: —Water—table.—depth SEPTIC TANK ❑ Type/Mfg W :Capacity No. Compartments t` PKG. TREATMENT PLT. ❑ I9 ; Method of Disposal i Distance to nearest: Well Foundation Property.Line LEACHING LINE No & Length of lines' Total length/size c� + FILTER BED ❑ Distance to nearest: Well�.?Q�__ Foundati n- �- Property Line CS' SEEPAGE PITS Depth Size Number _ SUMPS Ll Distance to nearest: Well f 0— Foundation 4' �_ Property Line DISPOSAL PONDS ❑ 1� 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 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- lion laws of California." IN The applicant mu I fora r ire nspections. Complete drawing on reverse dpj Signed X ' Title: Date: ` FOR EPARTMENT USE ONLY a M Application Accepted by Date ' Area 2- or Grout Inspection h I �' Date..4 �,-^Final Inspection by Date L< Additional Comments: ❑ Stk 466-6781 ❑ Lodi li369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 :r I�I i FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. rEH 13-24(REV.1/"51 Oil (�Z�q I i�J' , EH 14-26 ;