88-1517 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA c Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin { Local Health District. E Job Address City Lot Size 747d 7-5 PM Owner's Name Address Phone .S^ Contractor-_a�.�� Address License No. Phone TYPE OF WELL/PUMP: NEW 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 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 M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I I Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth t=iller Material (Below 501 7KI TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) 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 k r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments !f[ PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Property Line Cry LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: ; Well Foundation Property Lirie SEEPAGE PITS ['I Depth Size Number SUMPS L-1 ' 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 Diltrict. 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 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 subiact,to workman's compensa- tion laws of California." j The applicant must call for all required inspections. Complete drawing on reverse side. f Signed X Title: Q'-GC z144Date:_ .// FOR DEPARTMENT USE ONLY t Application Accepted by `-' V Date l Area p PT Pit or Grout Inspection by. // 7 Date Finnan Inspection by ` Datfe 1 Additional Comments: LO UG 36 �7��C/ 0� �'z'r G�C c ❑ Stk 466-6781 ❑ Lodi -362 ❑ Manteca -7104 ❑ Tracy 835-6385 U V,Q_t +0 �.p Applicant ,Return all copies tn- Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,-Stk_., CA 951201 J� FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. ' t.t FE 13-24 tREV-t/H 51 INFO 3S s i'J ��if /� !V EH 11-26