88-2933 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 made in compliance with San Joaquin CountOrdinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address > r_L_ ' fG City%S &fON Lot Size PM Owner's Name f2v R, ZA—dress r� p Phone✓ � Contractor s ense No Phone TYPE OF WELL/PUMP'. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION In PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottum ❑ Manteca f Wel! Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack © Tracy Type of Casi Specifications ("7 Public n Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation �_Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ O Well Destruction ❑ Well Diameter Sealing Material itop 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is 11 available within 200 reef.) Installation will serve: Residence 6 Commercial— Other Number of living units: J— 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. D Method of Disposal y Distance to nearest: Well, Foundation _ Property Line T LEACHING LINE ❑ No. & Length of lines Tata! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line c SEEPAGE PITS I I Depth Size_ Number SUMPS Ll to nearest: WeIJ{ Foundation Property Line�60 7 C, 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 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 subject to workman's compensa- tion laws of California." The applican�cre�nd s 2'on �Completedron SignedX d/6�f/ ry � e.e { p a FOR_DEPARTMENT USE ONLY y Application Accepted by . Date / 4,0A ea Pit or Grout Inspection by Data 1 Final Inspection byODate < O Additional Comments: 6-. O ❑ Stk 466-6781 ❑ Lodi 36.9-3621 © Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED dY DATE PERMIT NO. +.EH 13-24 I REV. /x 57 '/O O _ 2 EH 14-26 / j�