88-2001 - 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 TYEAR 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. Job Address a SG t(f �� /�N — City + {4G Lot Size PM / Owner's Name I W Address G rcff �dtr✓ �4+ �STSr�ePhone Contractor qCA C_r— Address 0 dy License No. `��$� of Phone a' TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL AREA STRUCTION SPECIFICATIONS E ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia..of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T y Type of Casing Specifications f 4. C1 Public (7 Other Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. De I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pum ' H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filter Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: I Number ofbedrooms 3 Character of soil to a de�ptthh °f 3 feet: A4, b_Z Water table depth SEPTIC TANK L� Type/Mfg 10 QIVAGre}Pi Capacity _ No. Compartments a PKG. TREATMENT PLT. ❑ t ! Method of Disposal i Distance to nearest: Wellr(�D Foundation_.) Property.Line LEACHING LINE V*--No. & Length of lines _ Tntal'length/size wl r FILTER BED ❑ Distance to nearest: Well Foundation _--._._ Property Line - t t SEEPAGE PITS I Depth Size Number t SUMPS ❑ Distance to nearest: Well Foundation 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, 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 lot ail requir d inspections. Complete drawing on reverse side. Sig' " Sined X ,t� Title: ��-�� ,Date: a ' FOR DEPARTMENT USE ONLY Application Accepted by 'f% Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CI Tracy 835-6386 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO t�A�MOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. r.EH 13-24(REV,1/6 5) Ip�co EH 14-26 t