88-122 - Laserfiche WebLink

Home Browse Search

4 s APPLICATION FOR PERMIT r � �^ 4 SAN JOAQUIN LOCAL HEALTH DISTRICT (�• ` 1601 E. HAZEL T 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 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. Job Address ` City Lot Size PM Owner's Name ice, Address Phone Contractor Address License No.5��Phone?y.9-J-1w/ TYPE OF WELL/ UMP: NEW LL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PI INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR ICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications i`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation pprox. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Typ 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 f l REPAIR/ADDITION t I DESTRUCTION ( o septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depthi of 3 feet: 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`,!ED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I, Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL POt±pS ❑ I hereby certify that t 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 applicant st all for all required i spectio . Complete drawing on reverse sic;e. Signed X 49 Title: ��-a6y�%��'L�!' T! �– Date: / .tz—rpop/ FOR DEPARTMENT USE ONLY ypplication Accepted by `CM �1 Date – Area e'-- 4 t 1J �it or Grout Inspection by Date Final Inspection by Date 2`fly Additional Comments: f 7 7 7 ❑ Stk 466-6781 ❑ Lodi 369-1621 ❑ 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. + EH 14-281EV.i/R5) t/ �X��a