88-943 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone {2091 466-6781 d� v PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (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 Couny Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' r Job Address City f Lot Size PM F� Owner's Name Address .5A-&F— J9- �� Phone ContractorL&At,t 21 MAS Address4,SVO F_ F '"/940111 STLicense No, Phone TYPE OF WELL/PUMP:. . IINEW WELL ❑ 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 R INTENDED USE TYPE OF WELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca r Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public F Other In Delta Depth of Grout Sea] Type of Grout Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump Z,9491iVe— H,P. State Work Doneple 1 #16 Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION t 1 (No septic system permitted if public sewer is v� i, available within 200 feet.) installation will serve: Residence Commercial_ Other 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 of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well 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 rules and regulations of the San Joaquin Local Health District. ' Home owner or licensed agent's signature certifies the following: "I certify that in the performs c6 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. + I Signed X p¢Title: . „-„- Date: '” ^•LS 5a - F EPAR1�ENY,•,,USE ONLY Application Accepted by SF Date tAfi� l Pit or Grout inspection by Date Final Inspection by ate � . v Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 ENVIROMENTAL HEALTH Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave. P.O. Box 2009, Stk., CA 9VORMIT/SERVICES FEE l , INFO A UNT DUE AMOUNT REMITTED CASH RECEIVED'BY DATE PERMIT NO. + EH 13-21 tREV.1/R5) 4C EH 14-26