88-2366 - Laserfiche WebLink

Home Browse Search

:1 1 a � APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT '1601 E.,HAZE 1 T 0"N'iE,, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A1- HP"L it {Complete in Triplicate) �V� RM ISR,qtiCs 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 �.r 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 •! r Ala Cit t Size PM Ownerame E`7 Address l �W0'0 Phone /�1'— 4 , Contract ss License Nor Phone TYPE OF WELL/PUMP: NEW W LL ❑ WELL REPLACEMENT ❑ 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 •❑ Domestic/Private ❑,Gravel Pack ❑ Tracy Type of Casing Specifications f-I Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout --- 11 1 Irrigation I -Approx. Depth I Ea tern �}'face 5 al Installed by .ti,Repair Work Done 03�Type of Pump H•P. < State Work Done ,Well Destruction ❑ Well Diameter Sealing Material (top 50'1 JF Depth Fillet Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is � available within 200 feet.) i Installation will serve: Residence_ Commercial- Other Number of living units: Number of bedrooms Character of soil to a depth'of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity 1. No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal {S1 Distance to nearest: Well Foundation— Property.Line r i LEACHING LINE ❑ No. & Length of lines -S I Total et ngttLsize FILTER BED ❑ Distance to nearest: Well Founda"tion f _ p4 rty Line i SEEPAGE PITS 11 Depth Size .--.�`y='�`}�-"� � _�_ � Number I ' SUMPS L� Distance to.nearest: Well -Foundation Property Line DISPOSAL PONDS ❑ 6 hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and reguI do the a oaquin Local Health Diltrict. Home owner or ' en"sed agent's si ature certifies the follow- g: "1 ce ify that in the performance of the work for which this permit is issued, I shall not employ any p son in such manner s to becom subject rkma ' compensation laws of California."Contractor's hiring or sub-contracting signature certifies the ollowing: "I c, ify th the pe n of a work r)vvhfchtthis it is Io issued, I shall em tion laws /California." p Y persons subject to workman's compensa- i The applic t must a quir ns. Complete awing on r I 5 ..y .. ....y / / �✓yQ 1 :Signed Title: Date: 11 FOR DEPARTMENT USE ONLY (� Application Accepted by x � , z_e� : Date Pit or Grout Inspection by Date Final Inspection by J pate Wr/&, Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823.7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201. FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT N0. +.EH }241REV.1i951 EH i4-26