88-1275 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT y 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. 548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District I � - Job Address City Lot Size PM Owner's Name ` Y. Phone Contractor ensevNoPhone� Lo Of i TYPE OF Wtens ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION El 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 LJ Open Bottom ❑ Manteca Dia. of Well Excavation f t Dia. of Well Casing ❑ Domestic/Private El Gravel Pack- C1 Tracy Type of Casing Specifications 4 ri Public f_7 Other Ll Delta Depth of Grout Seal I I Irrigation A Type of Grout �.. pprox. Depth I ] Eastern.. Surface Seal Installed by Repair Work Done ❑ Type of Pump ] H.0 State Work Done_ r Well Destruction ❑ Well Diameter I Sealing Material (top 50'1 Depth ; y Filler Material {Below 50') F TYPE OF SEPTIC WORK: NEW INSTALLATION f REPAIR/ADDITION II DESTRUCTION I i (No septic system permitted if public sewer,is / Installation will serve: Residence IL I Commercial Other available Within 200 feet. - Number of living units: —I— Number!of bedrooms Character of soil to a depth of 31eeet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Ca acit t 1 y i P Y No. Compartments ` PKG. TREATMENT PLT. ❑ � !7 y Method of Dis osal 0 Distance to nearest: Well r - Foundation _ �Property Line — EACHING LIN ❑ .No. & Length of lines ~� - otal length/size FILTER BED ❑ Distance to nearest: Well Foundation L 1 (j Property Line _-_ SEEPAGE PITS i I Depth f Size NurJtber UMPS ❑. Distance to nearest: Weil Foundation._ ' _[ Property Line DISPOSAL PONDS ❑� , : - —,..�_ -.. 1 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,1 shall employ persons subject to workman's compensa- tion laws of California. I The applicant m st call for all.'re uirviRpections. Complete drawingon rquprse side. L/J./� i _ Signed X T.-rtla: ' w. c Date: FOR DEPARTMENT USE ONLY Application Accepted by Date L/ e Area Pit or Grout Inspection Date Final Inspection by � Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 gg Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk. CA 95201 I a , _ FEE AMOUNT DUE AMOUNT REMITTED OK INFO CASH RECEIVED BY DATE PERMIT'NO. i EH 13-24 MEV.r i n 5) ' EH 14-26 �Z�