88-2433 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT VV SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 County Ordinancq No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ' �� City 1-6401 Lot Size t ®L " PM )�0 Gam— Owner's Name N m Address ^�� - Phone .3 3 V..?a Contractor Address �2f'S� sec��c � License No.-3pJ/'Y 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 F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. 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 ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial—.9ther Number of living units: I Number o b r oms _6 �© Character of soil to a depth of 3 feet: Lo Water table depth SEPTIC TANK � Type1Mfg. _ _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ `� �^ Method of,D^is`�josal ` Distance to nearest: well -XV/ Foundation J / Property Line 3ot� LEACHING LINE _I NO. & Length of lines d; Total length/size FILTER BED ❑ Distance to nearest: WeII f `Foundation-t-,0Ly Property Line SEEPAGE PITS L.V'Depth __Size � N/umber SUMPS Ll Distance to nearest: Well„j _ Foundation -2 Property Line rT 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 Di§trict. 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 foo which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicarg must call fAr all quired inspections. Complete drawing orevgrse,side. / /� Signed X Title- Nei Date: 1t"'" • FOR DEPARTMENT USE ONLY Application Accepted by Date '"! Area 12pp Pit Grout Inspection by Date Final Inspection by 91 Date y� 0 Additional Comments: ❑ Stk 466-6781 ❑ Lodi "369 3G1T_..._._ _❑-Manteca 823-7104 -0 Tracy 835=8385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMII�T/NO. +.EH 13-24(REV.1/95) �/�1 Gv �) Q J/� zz EH 14-26 ///