87-80 - 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 1 YEAR FROM DATE ISSUED (Complete in Triplicate) [; r, 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 . � 7T�/V L5t/Af& City - Lot Size PM ,l/f/��_�, 3 =. G' Owner's Name / i1/�( ?N�lll_�Address Phone v frt Contractor Address License No. Phone T ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1" - PUMP INSTAL--L- TION`❑SYSTEM REPAIR❑�'°" OTHER ❑ DISTANCE TO NEAREST: TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDAT AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR REA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation i Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of �. Specifications ❑ Public El Other � Delta Depth of Grout Sea } Type of Grout N ❑ Irrigationt �Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type,of Pump' 'H%P:-' �' ^°" State Work Done Well Destruction ❑ Well-Diameter Sealing Material (top 501 t W Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONX, (No septic system permitted if public sewer is \� C' available within 200 feet.) I 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. ❑ f 'Method of Disposal \� Distance to nearest: Well Foundation 4 Property Line r ' LEACHING LINE ❑ No. & Length of.lines Total length/size FILTER BED ❑ Distance to-nearest: Well Foundation -Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS y------EZI---Distance to-nearest: Well Foundation Property Line DISPOSAL $ OS L 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 j 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 workma`n'i`compensation laws of California."Contractors 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 a The applicant mut call for all r ui ad inspe '9nf. Complete drawing on reverse side. SigneX r__ �t�__ _ Title: JYI-�- Date: { RTNI T USE ONLY T i,/y Application Accepted by Date /r c+ Area d Pit or Grout Inspection by _ Dateyy� _AFinal Inspection by Date Additional Comments: i(lLli� DfJ�X _- ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104' .. ❑ Tracy 83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO ^� + EH 13-24IREV.1/a5) r L —{}�/ A0 ?7-vr% EH 14.28 Jov