88-621 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMITIt SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �R LSA PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �p,L HSA (Complete in Triplicate) p R[e�111{tet Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work JR described.This application is 6- 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 I Local Health District. Job Address ,7.. ° U 1'I Cbz' �• City Lot Size PM �-�-- v , Phone Owner's ?? ' Owner's Name 5 br r Address [/ 77 ! �-` Phone '139 I30 -Contractor s Address 41VOt License No. � TYPE OF WELL/PUMP: NEW WELL ❑ i " 0%, WELL REPLACEMENT `DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR O. OTHER ❑ SEWER AA' ' y: `DISPOSAL FLD. PROP. LINE �(LL DISTANCE TO NEAREST: SEPTIC TANK _ f __ SEWER LINES °h--� 1 f 'FOUNDATION _ �" _- ..__ AGRLCULTURE WELL _r 0TH WELL — - PI FS!_SUMPS INTENDED USE TYPE OF WELL PROBLEM R1✓A"> C�L1CATF 6 CA IONS ❑ Industrial VOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 " Specifications `' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing p �� I' ri Public f i Other fl Delta Depth of Grout Seal r Type of Grout . — �_ __,�.__...�.._ �. Irrigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. S ork Done {i 1 s f Well Destruction ❑ Well Di ter Sealing Material (top 50') D Filler Material (Belo. l P TYPE OF SEPTIC WORK:" NEW INSTALLATION 1.1 REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation'will serve: Residence_ Commercial_ Other 1 Number of living units: Number of badrobms , Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal !1 r { Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size I F FILTER BED ❑ Distance to.nearest:"� a Well 0 , oundation Property Line r t - - SEEPAGE PITS I i Depth ize Number _ .SUMP_S - - Ll-TDistance:to near 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, staje laws, and ` rules and regulations of the San Joaquin Local Health District:." Home owner or licensed agt3nt's signature certifies the following: certify that in the performance of the work for which this permit is issuer,./,shall not ure employ any person in such manner as to become suf3ject,to'workman's compensation laws of California." Contractor's hiring c sub c rkma t 'compatsa- 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- i - tion laws of Califo nia." t t t The applicant requir inspe omplete drawing on reverse side. �� R � : j ,,ems ,f" i s� Date: Signed X r!S I Title: 7'MENT_USE.ONLY....r —. .,..,r:...,..,.—•--�'--^.-` Date Area Application Accepted by t�;,` Pit or Grout Inspection by Date Final Inspection by Date } Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 AMOUNT DUE AMOU T REMITTED C H K RECEIVED BY DATE PERMIT NO. INFO / y{x H 1.019 , 'r '4(REV,1/H 5Y I✓ r "/e Yt 5 -