86-343 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. L Job Address � 6 City Lot Size PM Owner's Name `I� Address ? M'� Phone Contractor 71 Qio!�1 g Address f License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WEAL PMR- AIC9,, ❑ DESTRUCTION ❑ .,. PUMP INSTALLATION ❑ SYSTEM R AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE R LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC TURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBADe UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Maell Excavation Dia. of Well'Casing ❑ Domestic/Private ❑ Gravel Pack ❑ TraCasing Specifications ❑ Public ❑ Other O DeGrout Seal Type of Grout ❑ Irrigation _Approx. Depth AD'Tae Installed by Repair Work Done ❑ Type of Pump State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALtATI REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted`if public sewer is 6 available within 200 feet.) Installation will serve: Res Bence Commercial Other OQ Number of living units:T Number ofYlStfroohis' Character of soil to a depth of 3 feet- le depth SEPTIC TANK ❑ Type/Mfg PrArribo46Capacity No. CompartmentsT, PKC.:TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Po. & Length of lines r gsae FILTER BED ElDistance to nearest: W 1 ,foundation Property Line �- i SEEPAGE PITS ❑ ,Depth Size Number SUMPS ❑..-Distance to nearest: W 11 Foundation Property Line DISPO Al- PONDS ❑ ic I hereby certify that 1 have prepared A4 application and t at the work will be done in accordance with San Joaquin county ordirfances, state laws, and rules and regulations of the San J Local Health Di rict. Home owner or licensed agent's si 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 s+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." I The applicant must call for all reqir i ct' ns. Complete drawing on reverse side. Signed!X Title: Date: FOR DEPARTMENT USE ONLY K Application Accepted by L.� Date Q LA f took- Q p Pit or rout Inspection by Date Final Inspection by Date Z-�-�S- Additional Comments: hi' 1i' x r ❑ 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. Bpi st, CA'95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED DATE PERMIT'NO. + EH 13-24(REV.1ie5) f-4 Z.— EH `�'–�O, ©O - .l MEH 1428 Y i