88-2954 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . Job Address � � • S�. OL IV AVC- IM City © \ QQot Size PM Owner's Name Address �r AL1 OF A 0/f Phone fo oC Contractor D writ Address TYPE OF WELL/PUMP; I� License No, Phone NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK " OTHER ❑ I 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Type of Casing Specifications M Public C1 Otlier ❑ Delta Depth of Grout Seal I I irrigation --Approx. Depth I I Eastern Type of Grout Repair Work Done E3Type of Pump H P Suriace Seal Installed by E e Well Destruction El Weft Diameter State Work Done Sealing Material [top 50') ------------------- Depth�M Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION IA REPAIR/ADDITION I I DES 4 RUC.TIO (No septic system permitted if public sewer is Installation will serve; Residence, Commercial, N%available within 200 feet.) Other�� Number of living units: "I,Number of bedrooms Character of soil to a depth of 3 feet: ❑ Ty SEPTIC TANK Water table depth pelM p PKG. TREATMENT PLT. [71 No. Compartments Method of Disposal Distance to nearest;`" Well Foundatio+n Property-Line , LEACHING LINE Ll No Jl& Le f ,� FILTER BED ' S Total length/size ❑ Distance to nearest:', �M el �+ U �� - Property Line Lr1V1r6n&. pa a SEEPAGE PITS " I1 Deptth Size Number SUMPS Ll Distance to nearest: Well DISPOSAL PONDS ❑ �` - Foundation Property Line I hereby certify that I have prepared this application and that the work will be done tri 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 thavin the employ any person in such manner as to become subject to woman's compensai on 1performance ws of Califorrnia," Contractor'sthiringl or sub-contracting s�permit is issued, lsignaltnot u e 1 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 applicant must call for all required ins I q Pections. Complete drawing on"reverse side. " Signed X c" Title: r FOR DEPARTMENT USE ONLY, Application Accepted by r,/NC--.— _ � "' Date v Area Pit or Grout Inspection by Date Additional Comments: Final Inspection by I` Date I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: En ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ., I FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. EH 14-26 ��s �� +.EH 13-24 IR EV.t 5) y p