88-2068 - 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 r PERMIT EXPIRES '{YEAR FROM. DATE ISSUED I (Complete in Triplicate) Application is.heteby 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. Job Address City Lot Size PM Owner's Name t.C.� &��A,�ddress (,V/�f/ [ Z& Phone Contractor Address License No, �0�/ Phone -S"741 TYPE OF WELL/PUMP- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ rte W373T--Z— PUMP INSTALLATION ❑ SYSTEM REPAIR ❑, OTHER ❑ i 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 �`Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing '" Specifications f`l Public ❑ Other ❑ Delta Depth of:Grout Seal Type of Grout I Irrigation =.-Approx. Depth I ).Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump -H.P. 1. State Work Done _ Well Destruction El Well Diameter Suing Material-(top 50') Depth Filler Material (Below 501' �# TYPE OF SEPTIC WORK: NEW INSTALLATION iJ' REPAIR/ADDITION l-) DESTRUCTION 11,LNo septic system permitted if public sewer is available within 200 feet.] 1 Installation will serve: Residence Commercial's_ Other 1+ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth �— SEPTIC TANK , fW Type/Mfg ; Capacity d No. Compartments PKG. TREATMENT PLT. 0 i r Method of Disposal ` Distance to..<`nearest: Well ---rFoundation Property Line th of lines — OF Total length/size LEACHING LINE Ur No. &.Leng ° R 'FILTER BED ❑ Distance to:nearest: Well Ant Foundation Property Line a SEEPAGE PITS a 11Depth Size M l Number f SUMPS _. L Distance to nearest: Well Foundation - Property Line . DISPOSAL PONDS AD % I y I hereby certify that I,have prepared this application and that the work will be done in accordance with San Joaquin county.ordinances, state�Iaws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "t 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 rtormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californ' L The applicant m all for all re i spections. Complete drawing on reverse side. Signed X Title: t1N/ Date: ; l F ARTMENT USE ONLY Application Accepted by Date Area wm Pit or Grout Inspection by Date Final Inspection by Date do Additional Comments: ❑ 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 CK FEE INFO AMOUNT DUE AMOUNT REMITTED )gC(ASH f�RECEEIIV}ED BY fib{ DATE aPERMIT'NO. I ,� tEH13-24iREV.limb) ,tC�� /4 fV f l H J " ///Fr Ori-m&g i EH 14-2a R J