CO2500681 (4) - Laserfiche WebLink

Home Browse Search

t , APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZETON AVE., STOCKTON, CAt- 4 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (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.ThisappNcation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 for well/pump and the Rules and Regulatkms of the San Joaquin Local Health District. Job Address ^.City Lot Site PM Owner's Name / „+-'662(-4 Address.- . ti a`.t i Phone Contractor dress icense No Phone Com+ TYPE OF WELL/PUMP: NEW WELL ❑ = WELL REPLACEMENT ❑ DESTRUCTION ❑' t ,r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ l OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK l f SEWER LINES DISPOSAL FLD. PROP. LINE t ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� - r INTENDED USE TYPE OF WELL'`;-'PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial ❑ Open Bottom ❑ Manteca , Dia.of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack 0 Tiacy Type of Casing .— -4 Specifications CI Public fj, ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of,Pump ? ; H.P. �� State Work Done N Well Destructioit. 0 Well Diameter ` - Sealing Material It 501 1 Depth Filler Material(Below 501) ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION VNo septic system permitted if public sewar is available within 200 feet.) t Installation will servo: Residence_ Commercial_ Other Number of living units:._ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK C1Type/Mfg �(1xj s�'r�l Capacity No. Compartments 0 PKG. TREATMENT PLT. ❑ ' pJ Method of Disposal Distance to nearest: Well Foundations -A Property Line 'f t .,; LEACHING LINE ❑ No. & Length of lines _ Le Total-length/sizs' `J ILTER B ❑ Distance to nearest: Well C)-__ Foundation.. Id Property Line SEEPAGE PITS ❑ Depth I Size Number SUMPS ❑ Distance to nearest: Well_ Foundation Property Line �1 DISPOSAL PONDS ❑ l 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 iagulations of the San Joaquin Local 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, 1 shall not employ any person In such manner as to Become subject to workman's_compensation,laws of.Califomia.".Contractors hiring-or sub-contracting signature certifies the following;"I certify thafln the•parforrtiance'of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." , The applicantor, Tqu,r pectiona. Co pl drawing�07erse side. /J Signed Title:-��'/. T Date: FOR DEPARTMENT USE ONLY AppliceYron Accepted by *r Date ' Area 1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 823.7104 ❑ Tracy 835.8386 Applicant- Return all copies to: Environmental Health Parmlt/Services 1501 E. Hazelton Ave.;P.O. Box 2009, Stk., CA 95201 y - INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYDATE PERMIT'NO. ENI 3u(RM+/a 6) 0 EH W25 1