88-663 - Laserfiche WebLink

Home Browse Search

k APPLICATION FOR PERMIT { SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. Job Address0 �`� "' C�- ` fi City Lot Size PM Ro`e4bo 1�fl�ite.Ro OS 14-i..3 iJC� LAID Owner's Name Address � - � Phone ` Contractor � AddressW W Ak-k-oL.f' Sn� License No- � " Phone`77 ,TYPE OF WELL/PUMP: NEW WELL ❑. WELL.REPLACEMENT-❑ /t DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANdfS L FLD. PROP. LINE FOUN ION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ .INTENDED USE TYPE OF WE-tt,, PROBLEM AREA CO UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom nteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack• ❑ Tracy Type of Casing Specifications f"1 Public ❑ Other M to Depth of Grout Seal Type of Grout C I i Irrigation �_ApproxI Dep t 1 Eastern Su ca Seal Installed by Repair Work:Dane ❑ Type of Pu r. �•-H-p•"- State Work Done Well Destruction ❑ We lameter Sealing Material (top 50 Depth Filler Material (Below50'1 TYPE OF SEyPTIC W RK: NEW INSTALLATION i I REPAIR/ADDITION f P DESTRUCTION -fNo septic system permitted if public sewer is available within 200 feet.) Installation!will serve: Residence_J Commercial-/ Other + I f f . Number of�living units: Number of bedrooms Character of soil to a depth of 3 feet:` `{ r " t t Water table depth SEPTIC TANK 'Type/Mfg -r Capacity N6._Compartments PKG. TREATMENT PLT. ❑ t 1 ! rf � Method,of Disposal ) s Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No: & Length of lines ° Notal length/size FILTER BED ❑ Distance 'to-nearest: Well Fouddation Property Line - ,SEEPAGE PITS I 1 Depth _t Size Number' SUMPS l _❑ .!Distance-to nearest:, ,Well Foundation Property Line )DISPOSAL PONDS ❑ I t - 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. �.f ,Home owner or licensed agent's signature certifies the foNowing: "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 Californiavi " The"applicarequir inspections. Coinpleie-drawing on reverse side.LA I rgned X ' r � 7 IQu� Title: Date: FOR DEPARTMENT USE ONLY` V Application Accepted by �.6 Date Area Pit or Grout Inspe ' n by Date Final Inspection by Date. 1- r Additional Comme n'qw ,,.64/L,4 ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mont 3-7104 ❑ racy 835-6385 f Appllcant - F1turn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20%, Stk., CA 95201 I x FEE AMOUNT DUE AMOUNT REMITTED INFO CASK RECEIVED BY DATE PERMIT'NO. C�] + EH 13.241REV.,/x51- � - �S ao Z -� EH 1429 -. t