88-2556 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ('� Job Address City h(%Vt l f_1 PM Owner's Name �� Z� Address ��f j Phone Contractor l,�pkL.` � t° Address..._ 1SO LOfC.�y" �tLicense No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑�raPy Type of Casing Specifications r-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ! I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done L1 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter :` Sealing Material (top 50') Depth" % r —Filler,_Material„[Below_501 TYPE OF SEPTIC WORK: ,NEW INSTALLATION 1.1 REPAIR/ADDITION RUCTION I I IN. septic system permitted if public sewer is } " t / L�1 available within 200 feet.) Installation will serve: Residence Commercial'-+ Other r " I Number of living units: f Number of bedrooms_ i t r 4 Character of soil to a depthjof 3"feet: 5, Water table depth SEPTIC TANKTpelMfg Capacity Z[-�Cr3C'� No, Compartments PKG, TREATMENT PLT. ❑ Method of Disposal i' ' ^t Distance to nearest: Well s d Foundation_ 0 Property Line LEACHING LINE �1;Nts & Len th of lines 9 Total length/size FILTER BED' 1 ❑ Distance to nearest:n Well�foundation Property'L"ne E • I SEEPAGE PITS11 Depth Size Number r SUMPS 0'� Distance to nearest: Well Foundation `Z Property'Line 4, 4 DISPOSAL PONDS ❑l '� '+�` . i 5r•C�I ,A , FI 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 ro� 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 law's of California."Contractor's hiring or sub-contracting signature the following: "I certify that in the performance of the work for which this permit i gissued, I shall employ persons subject to workman's compensa- tion laws Californi t The applic nt t ca for II re ed i s ctio s. _m drawing onn;:�A ¢,Signed Title: 1 Date: �� y i° r F. DEPARTMENT USE ONLY Area / �Applic -1 7 cry' ation Accepted by A r I Date Pit or Gro ut. by Date Final Inspection by Date Additional Comments: _ 0 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, Stli CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH ~RECEIVED'By DATE PERMIT'NO. r.EH 13-24(REV.i n 5) EH 14-26 iC) ^[