88-2808 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZEL T ON AVE., STOCKTON, CA Telephone1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,�; $`W FAJ"-A, = (Complete in Triplicate) 40 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 Ordinanco No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name Je J ddress 1 f ,, 1�'1__— Phone Contract � Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ At PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES DISPOSAL FLD. PROP. LINE I FOUNDATION""" "—AGRICULTURE WELL OTHER WELL-- SPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 9'1 D Domestic/Private L7 Gravel Pack ❑,Tracy Type of Casing Specifications 1-1 Public I{-I Other ❑ Delta Depth of Grout Seal Type of Grout _ v I I Irrigation _-Approxi Depth-[ I Eastern Surface Seal Installed by _ Repair Work Done L7 Type of Pump H.P-, State Work Done_ d Well Destruction ❑ Well Diameter Sealipg Material (top 50') Depth c Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION`f(f (No septic system permitted if public sewer is . - I available within 200 feet.) Installation will serve. Residence _ Commercial_ Other / Number of living units: Number of bedrooms w Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK r I-X Type/Mfg " Capacity No. Compartments l *PKG. TREATMENT PLT. p Method of Disposal Distance to nearest: Well Foundation " Property Line LEACHING LINE` ❑ No. & LengthRof lines Total length/size FILTER BED * O Distance to nearest: Well Foundation 4 Property Line - ' I SEEPAGE PITS l I Depth I Size Number SUMPS Ll Distance to clearest: Well Foundation Property Line s 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.• 1k Home owner or licensed agent's signature certifies the following: "f 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." 1 i The appli t m t call for all requi a inspections. Complete drawing on reverse side. Signed Title: __ FO EPARTMENT USE ONLY Application Accepted by Date Aroa � � / � / �y it Pit or Grout Inspection by Date Final Inspection by - G`Tt..(� _ Date l,2 Additional Comments: a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO MOUNT DUE AMOUNTREMITTEDC 5R 77 RECEIVED BY /DATE ,(f PERMIT''NNjO. ."EH 3-24(FIEt/H5) Q r [-R!9 //� /_//J / / Jr 5/Jt'/t ) EH 14-26 i Tom" / f / �G(fV g