88-2811 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA � Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED b (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 � CA/u�f-'a E.�P ��// City Size PM Owner's Name[Q( ,q "Adess L� Phone L .`Contractor f/ Address . License No.-�Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INST LATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURgWlrLL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ROBLEM CONSTRUCTION SPECIFICATIONS ❑ Industrial' ❑ Open Bottom' ❑ eca Diarof Well Excavation, Dia. of Well Casing ❑ Domestic/Private ❑ Gravel_Pack Tra Type of Casing Specifications- f 1 Public ❑ Other Cl Delta Depth-of Grout Seal Type of Grout _ I I Irrigation - __A x. Depth I I Eastern Surface Seal Installed by ' Repair Work Done ❑ Type o ump H.P. State Work Done Well Destruction ❑ Well Diameter ,". Sealing terial (top 501 Y Depth j Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION fI REPAIR7ADDITION LI DESTRUCTION (No septic system permitted if public sewer is - _"'- '" - .available within 200 feet.) ltrl 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 _ ❑ 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 a FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line 1 SEEPAGE PITS C I Depth, Size _ Number SUMPS Ll Distance to nearest:+ Well Foundation Property Line i DISPOSAL PONDS ❑ P I hereby certify that I have prepared this application and that the work wili`be d6i> iin accordance with San Joaquin county ordinances, state laws, and-- rules nd/rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies Lthe.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.Zorkman'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 II for all required ins, ctiort§. Co plate drawing on reverse side. Signed X _ Title., Date: or FOR DEPARTMENT USE ONLY L! y Application Accepted by Date T (�O Area Pit or Grout Inspect y Date (`Final Inspection by Date Additional Comments: 1\� t��'X�� . !�2 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82 - 104 ' Tracy 835-6385- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CKO RECEIVED BY DATE PERMIT'NO. +.EH13-24IREV.1/H5) co EH 14-26 - e... /J ?-20-© = /V]ay - ho.-G be";ns ft�q( vf