92-0049 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �/;� 1O ( r � t Telephone (209) 466-6781 ' W 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. Q- AVON e� 7 Job Address c'�U?�C� AVIV CityLATIMI�S Lot Size 7,1 .6r' PM Owner's Name 1 � l Address 1,W6 RA�� A�,C P� Phone �` Contractor 5ffo4AJ ddress License No. 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 2 Dia. of Well.Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications ('1 Public Ll Other ❑ Delta Depth of Grout Seal i 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 i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION b4(No septic system permitted if public sewer is -- - -a --—- —available available within 200 feet.) Installation will serve: Residence_ Commercial_ Other I Number of living units: + Number of bedrooms Character of soil to a depth 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 1 a LEACHING LINE ❑ No. & Length of lines iTotal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS f I Depth Size Number a 1 SUMPS ❑ Distance to nearest: 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, state laws, and f 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 for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica cor all requir pections. Complete drawing on reverse side. Signed Title: enAimaillL, Date: i KFOA EPARTMENT USE ONLY ApplicaQQtion Accepted by Date 4 7 q 6 Z— Pit or Grout Inspectio by Date Final Inspection by Date_FyC� 2 ' Additional Comments:'22. d D�LZ�❑�,�� El Stk 466-6781 Cl62 Lodi 369-31 Manteca 823-7104 - ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 CK 111 INFO AMOUNT ,�DUE � UNT REMITTED CASH RECEIVED BY ADATE PE9RMITNO.EH 13-24 I + EH 14-28(REV.i i x 5) 5,�1' 7 V C.IJV 2