87-3098 - Laserfiche WebLink

Home Browse Search

� h ro/ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA r 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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address /!� ` City r Lot Size e�f✓� 60 PM Owner's Name 7 Address e ! FIR Phone �D ' Coritractar [�[ —Address'—T'12' &" _.:License Na:0�b Phone C TY.P_E„OF..W.,ELL/PUM_ F'-_ NEW WELL ❑_ WELL REPLACEMENT ❑' DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ©1 I DISTANCE TO NEAREST: SEPTIC TANK S WER LINES DISPOSAL FLO. PROP. LINE 4 FOUNDATION AG ULTUR ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBA/ Dep TRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Maf Well Excavation Dia. of Well Casing ❑ DomesticIPrivate ❑ Gravel Pack ❑ Traf Casing SpecificationsI Publicf 1 Other l l Delof Grout Seal Type of Grout I t Irrigation _.-Approx. Depth I 1 Eas Seal Installed byRepair Work Done ❑ Type of Pump State Work Done_ 1 Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material IBelow 501 VL TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LI DESTRUCTION (No septic system permitted if public sewer is r available within 200 feet.) tit f Installation will serve: Residence_ Commercial 'Othe t 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 Disposal a t f f Distance to nearest: Well Foundation Property.Line LEACHING LINE x ❑ No. & Length of lines Total length/size l FILTER BED ❑ Distance to nearest: Well t�Foundation Property Line I 8 SEEPAGE PITS - t f I Depth �;' -Size l t Number ! SUMPS i ❑ Distance to nearest:"-• °Well Foundation t N' Property Line DISPOSAL PONDS a ❑ t 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." J{= y.-� •` ". 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 shalt 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." a The applicant must call r as quired jpspections. Cbmplete drawing on reverse side. < ? n Signed X ort_ Title: ____�!}-r��_ _ Date: r L .,,.,:.,.FOR_DEP_ARTMENT USE ONLY - r `- '1� t _ Application Accepted byj Date Area -,.•...�•.-�- -,� ...,-..,.�. • . �. �: _...--., - -.....`..�.,"..�...� Date Pit or Grout lnspectior� Date Final Inspection by F Additional Comments:1 1 l ❑ Stk 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 i FEE AMOUNT DUE AMOUNT REMIT-tED CK RECEIVED BY DATE PERMIT"NO. INFO - - - ..EH 13-24(REV.i i m 5) IF EH 14-26