88-548 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 7 Job Address —�/1fZ_7 / � ,_ ,(�" -T --- __ City 4401-"074Lot Size . V�C,- PM c Owner's Name A/v Address Qr, Phone dO :06?0 O Contractor Address—bayl IM0 Mid License No.,36SMI mm P h o n e 36 TYPE OF WELT./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 6N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f-I Public ❑ Other C1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION L75ESTRUCTION I ) INo septic system permitted if public sewer is available within 200 feet.)" Installation will serve: Residence — Commercial Other Number of living units: __[_ Number o Brooms . - Character of soil to a depth of 3 feet: Water table depth po SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ T Method of Disposal Distance to nearest: Well Foundation Property Line 3k LEACHING LINE Re'No. & Length of lines j © I Total length/size 0 r FILTER BED ❑ Distance to nearest: Well &0 f Foundation .36 t- Property Line 06 1 SEEPAGE PITS f-t- Depth `I Size_ 3� Number SUMPS ❑ Distance to nearest: Well QQ I Foundation.t I Property Line DISPOSAL PONDS Cl 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all req 'red inspections. Complete drawing on reverse side. Signed X i— xitl - .AICs.-- - Data: FOR DEPARTMENT USE ONLY € / Application Accepted.by Date� � 2- grea ! Y �-t or Grout Inspection by / Date Final Inspection by _`�qDate f 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, Sik., CA 95241 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 6Yit INFO DATE PERMITNO,/f CASH (o D V + EH1 -24iREV.iiH5f EH 144-28 777JJJ ,`/NN�