88-1208 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA 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 iLlations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regu Local Health District. 71 M City Lot Size P Job Address j ,[� / J �� r N/ <•I Address 2 g� �✓ Phone Owner's Name f'�;9 Contractor /jam Address License No. Phone i TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13 DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casing Specifications ❑ Domestic/Private L-1GravelPack ❑ Tracy 9 [� Other ❑ Delta Depth of Grout Seat Type of Grout. I"1 Public 1 I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Weil Diameter Seating Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 4 I REPAIRIADDITION I I DESTRUCTION (No septic systhin m permitted if public sewer is avaeetJ Installation will serve: Residence ____ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS { I Depth Sire Number SUMPS l_1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 Oi$ttict. g: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the followin 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 mu'si�atl or,all require �nspections. CL7,tete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Z� ,' Z Date Area Pit or Grout Inspection by Date Final In action by Date W" Additional Comments: ❑ Stk 466-6781 ❑ Lodi 1 Cl Manteca 823-7164 Tracy 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1 1 Hazelton Av ., P.O. Box 2009, Stk. CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. (NFD r EH 13.24 4REV.i�As J EH 14.29