87-1533 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT : SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,.STOCKTON, CA S ;c j 'Telephone (209) 466-6781 ,,. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r. ` 133 _. . (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.-648 for sewage,or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` V.- $ Jab Address {_� - City Lot Size -:5-4 913M D�. { Owner's Name Y -.r2� � s �'! ' ` --� � Phone Contractor Address License No. Phone TYPE OF< ELL/PUMP• NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION A CULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ON UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca D- . Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack E3 Tracy Type of g Specifications ❑ Public ❑ Other " "D Delta Depth of Grout �al _ Type of Grout ❑ Irrigation �4pprox. Depth El Eastern Surface Seal Installe Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction . ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') Q TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 9ILNo septic system permitted if public sewer is available within 200 feet.] Installation will serve: . Residence—t-� Commercial_ Other (� li Number of living units:' Number of bedrooms I Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well - Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i I } j SEEPAGE PITS ❑ Depth Size Number SUMPS. ❑ Distance to+ nearest: Well Foundation 'Property Line DISPOSAL PONDS ❑ ;I 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." l The applicant must call for a1I requi ed inspa tions. rTplate drawing on reverse side. �y Signed XQ 40A, Title: Date: I� FOR DEPARTMENT USE ONLY Application Accepted by Date Z-Z` Area ' Pit or Grout Inspection b Date Final Inspection by-4 Date Additional Comments: a t ��e! 353, / �- ❑ Stk 466-6781 ❑ Lodi 369-3621 O 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 1 FEEAMOUNT DUE p AMOUNT REMITTED _CK RECEIVED BY DATE PERMIYNO. INFO + EH 13-24(REV.4/H5) / 7 1 EH 14-28 / 11 _