88-550 - Laserfiche WebLink

Home Browse Search

0 APPLICATION FOR PERMIT AIASAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA SCANNED 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. / fJ Job Address _ �CC,I�s^ 1�-�_- City Lot Size y� PM Owner's Name KBlJ d�5 Address Phone Contractor 4-o E• Address 7 .t16 "4EZZ, .2�,4 /56L.icense No. 171X41-76 Phone TYPE OF WELL/PUMP: NEW WELL ❑ . WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 I DISTANCE TO NEAREST: SEPTIC TANK —SEWER LINES-.... - . DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL O Lt1 PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEMAREA CONSTR N SPECIFICATIONS © Industrial ❑ Open Bottom ❑ Manteca - :of-Well.Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack - ❑ Tracy' Type of Casing -- Specifications M F1 1 Public n Other I l De Depth of Grout Seal Type of Grout _ I I Irrigation --Approx Depth""- Eastern - Sciriace'Sdal Installed'by Repair Work Done ❑ Type of Pump H,P. State Work Done IN i Well Destruction ❑ Well Diame Sealing Material (top 50') Depth' a A ` Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION DESTRUCTION l l (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: 'Res' ence , Commercial_ Other Number of living units: r � Number`of bedrooms '. ;T S Character of soil to a depth of 3 feet: - x Water table depth SEPTIC TANK ❑ "Type/Mfg 15rinlEr Capacity ` �No. Compartmentst PKG. TREATMENT PLT. ❑ v s .e Method of Disposal r N_Distance to nearest: Well Foundation Property tine c. i f LEACHING LINE_ J� No- & Length of linesTotal length/size O `X FILTER BED ❑ Distance to nearest l Wela Foundation' ad Property Line J.O SEEPAGE PITS l Depth �� ' Size Y 3►r T Number SUMPS 11 Distance to nearest: Well /01 Foundation /_._, .��..__ Property Line /Q DISPOSAL PONDS ❑ % r her certify that I have prepared this application and that the work will be done in accordan6e 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�irl.the.•per.formance-of_the_work_for-which•this-permit•is-issued-i-shall-amploy-peisons subject fo workman's compensa- tion laws of California." The applicant must call for all required inspection omplete drawing on"feverse side. Signed X Title: bate: _. FOR DEPARTMENT USE ONLY - Application Accepted by Date Area Q Pit or Grout Inspection by Date .Final Inspection by Date✓ ' Additional Comments: _ � / f f S ❑ Silk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f 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 i INFO E CASH RECEIVED 13Y ;DATEPERMiT'NO. + EH 14-24 IpEV.i � EH 14-28 ��/ V' C./C,J (f `/"'�/// �UX ✓\Jl /V/