88-2540 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT ..� SAN JOAQUIN LOCAL HEALTH DISTRICT -'s4 1601 E. HAZEL T ON 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. 1862 for,well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 43 1 � f, .Z _ City ize PM Owner's Name �XS AddressPhoneLO [ y r pq Contractor � 5�_ License N0.30 a Phone.Y'7 — VS TYPE OF WELL/?UMP: NE ELL ❑ # WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANC NEAREST: SEPTIC TANK SEWER LINES T DISPOSAL FLD. PR AGRICULTURE WELL OTHER PITS/SUMPS INTENDED USE TYPE OF WELL P REA CON SPECIFICATIONS L7 Industrial ❑ Open Bottom Mant Well Excavation Dia. of Well Casing ❑ Domestic/Private r ❑ Gravel Pack Tracy Type of Casing Specifications C'I Public Gl OT ❑ Delta Depth of Grout Seal Type of Grout i I Irrigation —.-Approx. Depth I 1 Eastern -Surface Seal Installed by _ ERepair Work Don ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION I ] DESTRUCTION 1 {No septic system permitted if public sewer is available within.200 feet.) 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 I p Y P PKG. TREATMENT PLT. ❑ I Method of Disposal /h Distance to nearest: Well` Foundation Property Line t V LEACHING LINE ❑ No. & Length of lines Total length/size -. FILTER BED ❑ Distance to nearest: Well Foundation t Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl 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`accordan-6e 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."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." The applicant must call uir d inspections. Complete drawing on r verse side. Signed X Title: Date: a�CAre FOR DEPARTMENT USE ONLY Application Accepted by Date `Area Pit or Grout Inspection Date Final Inspection by Date 4 J7 Additional Comments: e GI ❑ Silk 466-6781 1 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMITN0. + EH 13-241REV.t/H5) y A EH 14-26 t-c0 � �-S