88-206 - Laserfiche WebLink

Home Browse Search

r� APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ! Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED i (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. L.+ Job Address rAlCity Lot Size PM Owner's Name `Q"fie_ Address _46� : f <�rf Phone `� U /0- t Contractor Address License No. Phone ( TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL., - _ OTHER WELL PITS/SUMPS :r INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS pp Vr © Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia, of Well Casing �} F1 Domestic/Private .❑ Grave! Pack El Tracy Type of Casing Specifications Fl Public Cl Other (=1 Delta Depth of Grout Seal Type of GroutCJ _ i I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I'l DESTRUCTION I INo septic system permitted if public sewer is / vailable 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 PKG. TREATMENT PLT. ❑ Method of bisposaI Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 1 Foundation Property.Line i 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 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 ust call for all required inspections. Complete drawing on reverse side. Signed X ( Title: 0C4_>k Date: L FOR DEPARTMENT USE ONLY r� Application Accepted by _, o �� Date? Area V Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ®� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 535-6385 f U �Ap[p�licant - Return all Copies to: /Environmental /Health Perim'it/Servi es 1601 E. Hazelton Ave., P.O. BQGr- �1�,,,,�s,�i�y-t:�Yj l�� ! `^r v' r0l��7D FEE AMOUNT DUE AMOUNT REMITTED , INFO CK RECEIVED DATE PERM Nb. n(I� �j rcrWrn :, + EH 1321(REV.I/x 51 ^n t,,�„ «.�