88-639 - Laserfiche WebLink

Home Browse Search

1. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA r i 4 w, Telephone {209} 466-6781 - , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED b (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 Salt Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. City Lot Size ��- PM Job Address _ k Phone Owner's Name s a Contractor Address~ a icense No. Phone TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT Of DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK-,— SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION \1_1z AGRICULTURE WELL OTHER WELL PITS/SUMPS ! INTENDED USE TYPE OF WELLS PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑.Industrial ❑ Open Bottom rI ❑ Manteca�* • Dia. of Well Excavation Dia. of Well Casing IL ❑ Domestic/Private ❑ Gravel Pack 11 Tracy Type of Casing Specifications M 1 Public ❑ Other L 1 Delta Depth of Grout Seal Type of Grout 11 Irrigation ____�__Approx. Depth [ I Eastern Surface Seal Installed by - R Repair Work Done ❑ Type of Pump H.P. State Work Done Y 7 Well Destruction ❑ Well Diameter Sealing Material (top 501 " Depth A Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [0' REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is available within 200 feet.) .1k .r _ t r Installation will serve: Residence L_ "Commercial.._ Other , y. ;•- l �� � \ i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method ofi osal I t r Distance to nearest: Well�-Foundation �• � 'Property.Line Y t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: - Well/_...Q.._V _ Foundation�.=.-. Property Line � r SEEPAGE PITS l I Depth 1 Size Number r ` G� SUMPS C1 Distance to nearest: Well f__ � Foundation Property Line ' \ 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 �Q rules and regulations of the San Joaquin Local Health Di§trict. 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 Califorriia." 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." A14 The applicant ust call for all require pections. Comp! a drawing a erse side. t l Signd X Title. Date: / r FOR DEPARTMENT-USE ONLY - ��• �. p 1� Application Accepted by — - Date .tea Pit or Grout Inspection by Date Final Inspection by — Date Additional Comments: " ❑ Stk 466-6781 - C] Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 v FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. INFO ({{� /f(J /,�J�/7 ////// 71 +.EH 13-24 IREV,t/R 5/ `^ \ `•' y EH 14-2d