93-0731 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 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 applidation 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 Cit Lot Size C&&AA PM Owner's N�ame Address �— Phone 922— Contractor Contract ' nse No� S ddress17LiceJ Phone w TYPEOFWELL NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEIIL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TeCasing_ON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Specifications i"1 Public ❑ Other ❑ Delta t Seal Type of GroutI I Irrigation _.Approx. Depth I I Eastern nstalled by Repair Work Done ❑ Type of Pump P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE -- TYPE OF SEPTIC WORK: NEW INSTALLATION [Al' REPAIR/ADDITION l I DESTRUCTION I I (No,septic system permitted if public sewer is rl ' / available within 200 feet.) C J Installation will serve: Residence ✓ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth s. SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method ofDisporal Distance to nearest: Well ,2 Foundation T -f Property Line 9 LEACHING LINE ❑ No. & Length of lines _ Total length/size _ V, FILTER BED ❑ Distance to nearest: Well Foundation D Property Line (� SEEPAGE PITS l I Depth Size _ umber SUMPS Ll Distance to neatest: Well/ <7d_ oundation 50,1241C 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, 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 Ast call f I required in ctions. Complete drawing on reverse side. (, Signed X Title: Date: OR EPARTMENT USE ONLY Applicati/Accepted by ci 4A Date tArea iv` or Grout Inspection by/—✓�' /��F'Lq at ��ZY Final Inspection by � / Dafb�i�J (/Additional Comments: ` �r~ Y— ( ✓/ / ❑ 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 AMOUNT REMITTED CK 4 RECEIVED BY DATE I PERMIT'NO. INFO CASH L� �73 + EH 13-24(REV.t/x 51 EH 14-28 om c v9 o 5 / / l