92-3511 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA c Telephone (209) 466-6781AD � /si � � PERMIT EXPIRES 1 YEAR FROM DATE ISSU�r f,/�j ``LF10f f �� 111 �C tlr 1/n, (Complete in Triplicate) �!/, `ALT Cn{ j�� c. NFyt�s�application is Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei d rp dr l�T made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and RegulatfA' he:`fan Joaquin Local Health District. lS��N Job Address 0YF"'�'! _ City - Lot Size PM rd ArA� Owner's Name UA N AddressPhone Sl-e-' 2 2 pp qy� Contractor�r�p Address$�J? W.RJOy'tSf�►.£�1 License No.(L;�i5R16��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0/9 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERX--?XpL0R1iWRY 50NN1 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 A 4 A,c ElIndustrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public i l Other Cl Delta Depth of Grout Seal Type of Grout i I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by - t Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 W Depth Filler Material 18elow 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) --� Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ElType/Mfg Capacity No. Compartments KG. TREATMENT PLT. ❑ Method of Disposal l3 Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size M FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 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 taws 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant �(must tc/ call for al squire inspections. Complete drawing on reverse side. If Signed X /T/yj/ � �'(.��/{� w Title: PRC4f��ll�1t"�i - Date: � — FOR DEPARTMENT USE ONLY r , i Application Accepted by Date I t. Area Pit or Grout Inspection by 4_KDate r� <t' �'' Final Inspection by Date 1r' Additional Comments: c r�� ❑ Stk 466-6781 1-1Lodi369-3621 ❑ 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 f , FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATEdz- PERMIT NO. INFO yp /CASH / '77-5511 y, S 1 +.EH 13-24IREV.tiµ5Y -7 �� ¢j�f ��`� 1` �"�" ` EH 14-2a C/ VV