88-2750 - Laserfiche WebLink

Home Browse Search

'I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I! (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. i Job Address ee^ ►V City'Y�� Lot Size/Old . Ml PM Owner's Name 1Z14W ,� P1 I'd Address Iy Phone Contractor 'I Address /1N'Q1 License No. Phone TYPE OF WELL/PUMP: ii NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SY,STEM REPAIOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " - a 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑,Tracy Type of Casing Specifications 1 f"1 Public n Other a ' �. Cl'belta r Depth of Grout Seal Type of Grout r I 1 Irrigation �'?Approx. Depth. 'I I Eastern Surface Seal Installed by ! Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well`Diameter Sealing Material Itop 50') n Depth Filler Material (Below 50') h TYPE OF SEPTIC WORK: NEW INSTALLATION i;l REPAIR/ADDITION l I DESTRUCTION i I Wo septic system permitted if public sewer is R I! available within 200 feet.) Installatio ill serve: Residence _ Commercial_ Other Number of livin nits: Number of bedrooms Character of soil to a th of 3 feet: Water table depth SEPTIC TANK ❑ pe/Mfg clay No. Compartments PKG. TREATMENT PLT. ❑ i. Method of Disposal Distance Well "Foundation Property,Line ii LEACHING LI C1 No. & Length of line Total length/size ' FILTE ED ❑ Distance to nearest: ! Foundation Property Line ! s �1 SEEPAGE PITS ti Depth Size Number SUMPS 0 Distance to nearest: Well dation 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, !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 required inspections. Complete drawing on reverse side. Signed Title:— �"� Date: 14;> FOR DEPARTMENT USE ONLY [' Application Accepted byQADate 9'f Area J Pit or Grout Inspection,bsy� Date Final Inspection by �i Date 1. Additional Comments: ` -k- 6✓". P4-V G.�` �- ��^ Z r�LL� uV t ,u �` r��f b f 1) Stk 466-6781 El Lodi it lig 3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 0 PV tn,ZY '�T Applicant - Return all copies to: Environmental Health Permit/Services 1601•E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 CLFEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. Itf ♦.EH13-241REV.a/H51 i 3 :5,00 r7ay `7So �4. EH 14.26 'i