88-993 - Laserfiche WebLink

Home Browse Search

F� 4 � APPLICATION FOR PERMIT � (Z�R SAN JOAQUIN LOCAL HEALTH DISTRICT zl 1601 E. HAZEL T ON AVE., STOCKTON, CA �_ �, Telephone (209) 466-6781 AIPR `. 1988 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED t1. (Complete in Triplicate) ENVIROMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hS=101UbSf_%is(;;§ication 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 qyu City Lot Size PM v Owner's Name Address Phone 10 X Contractor Address License No., P74/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENr❑ 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-SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �r Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Ll Other F1 Delta Depth of Grout Seal Type of Grout _ 1 I Irrigation _Approx. Depth�!! I I Eastern Surface/Seal Installed by on P Repair Work Done ❑ Type of Pump H.P. J2 State Work Done Well Destruction ❑ Well Diameter Za= Sealing Material ftop 501 r Depth /O ' Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIRlADDiTION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) - Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line j 3 LEACHING LINE ❑ No. & Length of lines Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: i Weil Foundation Property Line r rDISPOSAL PONDS----C7 4-- f -f 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 insuch nner as to became subject'to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I rt 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 o a requi d i tions. Complete-drawing on reverse s' e. Signed Title: Date: �I _ OR DEPARTMENT USE QNZLY Application Accepted by Date /� rArea Pit or Grout Inspection by Date Final Inspection by Tl f�—Lli "r1 ns Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT•NO. + EH 13-24(REV.Iin5) �/!� EH 11-26 ` `�O /�" �� 3