88-1449 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT V 1601 E. HAZEL T ON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address _f e � Fp City7T&11Lot �-Size PM Q Owner's Name /[/�'z /�7� /ter - Address %s ut ✓n— �3� "�' / Phone u` j�1 E P_ Contractor. f _i�I��/' S 5 Address Qlr;?/? e- 69 I' icense No. �Phone � jTYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER D DISTANCETO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.&Of PROP. LINE FOUNDATION _ AGRICULTURE WELL 71_!e� OTHER WELL �PITS/SUMPS d INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS jJ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation_ /p Dia. of Well Casing ,Domestic/Private ❑ Gravel Pack ❑ Tracy Type cf Casing Specifications „ I7 Public I 1'Ot er Cl Delta -Depth of Grout Seal � � TXrpe of Grout 11 Irrigation Approx. Depth I 1 Eastern �oSqrface Seal Installed by - _ Repair Work Dane ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop,50'jY ` Depth Filler Material (Below 501 [ n TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRlADDITION i.l DESTRUCTION l 1 (No septic system permitted it public sewer is available within 200 feet-) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms R Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ri I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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 wilt 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 subiect%to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: '9 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 applicaWii�a lt re u'e&.- spections. Complete drawing on rravveerse de. Signed X / Title: �'/� Date: 4aS FOR DEPARTMENT USE ONLY 1V_ Application Accepted by Date A a I r: � Pit or,.Gro Inspection by e_ ( Date �F/r Final Inspection by Date Additional Comments: El 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, Stk., CA 95201 FEE )NFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT-NO. 00 + EH 13-24(REV.fiHsl W �U !i1 n CQ "— ;p EH 14-26 a