88-2489 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA DD z� Telephone (209) 466-6781��`� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i h (Complete in Triplicate) I 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. Job Address �� d Q CityS� loot Size PM iOwner's Name - Address /✓fit sp Phone :i I �' r/ Contractor, G.� Address� M-2!&c7G �.. License No. _x'�'._Phone T TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ %* PUMP INSTALLATION ❑ SYSTEM REPAIR V� OTHER ❑ DISTANCE TO NEAREST:,.SEPTIC--TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _.INTENDED USE, - TYPE OFWELL -PROBLEM AREA F,CONSTRUCTION SPECIFICATIONS ID Industrial ❑ Open Bottom ❑ Manteca `Dia.-of Well Excavation" Dia, of Well Casing;' Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1Specifications Ci Public n Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation _._Approx. Depth " I II Eastern Surface Seal Installed by Repair Work Done Type'of Pump H.P. State Work Done Well Destruction El Well Well Diameter Sealing Material Itop 50 .i. Depth F - - r Filler Material (Below 501 (� I TYPE OF SEPTIC WORK: NEW INSTALLATIt]N-l'1 REPAIR/ADDITION l I DESTRUCTION € I (No septic system permitted if public sewer is s available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms I ti : Character of soil to a depth of"3 feet: �.d', Water table depth SEPTIC,TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �" k. Method of Disposal Distance to nearest: r Well Foundation Property.Line t t 'EACHING LINE ❑ No. & Length of lines Total length/size ` FILTER BED ❑ Distance to neatest: Well Foundation Property Line j Sx SEEPAGE PITS i I Depth � Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑. 1. 3 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 I and regulations of the San Joaquin Loca!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 y employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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." t The ap i t mu call for all requir specti s. Com to drawing on arse side. I Signed X Title: date: % 7 J 774 FOR DEPARTMENT USE ONLY !1 �y 'Application Accepted by _— Date 1 � Area lJ Pit or Grout Inspection by Date Final Inspection by Date til- Y !Additional Comments: L Stk 466-6781 ❑ Lodi 2369-3621 ❑ 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH132AiREV.tiH5) EH 14-26 VVV fir{/ r- / ca I iP !J t• i� "