88-2035 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE_ STOCK I ON, CA � r 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 p and the Rules and Regulations of the San Joaquin Local Health District. Job Address Q � "'� Cit Lot Size PM Owner's Nam Address Phone 00, {I Contractor AddressZ�J License tro."7`�Y.��_Phone TYPE OF WELL/PUMOV NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 0 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �M. Specifications M Public n Other fl Delta Depth of Grout Seal Type of Grout _ I I Irrigation _,-Approx. Depth I 1 Eastern Surface Seal Installed by illi Repair Work Done ❑ Type of Pump H.P. State !Work Done Well Destruction ❑ Well Diameter Seating Material (top 501 IM Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION [ I DESTRUCTIO I (No septic system permitted if public sewer is r available within 200 feet-) v Installation will serve: Residence_ Commercial_ Other r r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth j J� SEPTIC TANK ❑ Type/Mfg Capacity gyp. No. Compartments v PKG. TREATMENT PLT- O J1I 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 mi 'r SEEPAGE PITS I I Depth Size Number SUMPS L71 Distance to nearest: Well Foundation Property Line (> DISPOSAL PONDS ❑ 111 1 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. 1 J 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 sFall employ persons subject to workman's compensa- 1' tion laws of California." ��- The' applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: LelDate: Z-57—i2 gy II FOR DEPARTMENT USE ONLY IN. Il Application Accepted by Date / Area Pit:. i .or Grout Inspecti Data Final In`s-pection 6y Date Additional Comments: 0 wyo,6 L :D S✓�1�' S IIS e-6 h ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I V?—1 VC_L".) Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95201 FEE EE+ INFO AMOUNT DUE AMOUNT REMITTED C$ RECEIVED BY�� DATE PERMIT"NO, i• hIV {, J + EH 13-24.1 REV.i/H 57 / ' _ _ /}I