88-854 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA NUW � Telephone {209} 466-6781 PERMIT EXPIRES T 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, -- (.0 T -N Job Address CT�1'�1�� --+-L-�� c T� City Lot Size 130 PM �?U( Owner's Name�L-1�1 ( nlL �l�J� �S 60+ an Address Phone Contractor, :S i��Yl T _� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ - WELL_REP LACEMENT f DESTRUCTION C]PUMP-INSTA--LAATION-[I- —•� L=. SYSTEM REPAIR•❑ ----- OTHER...❑ DISTANCE TO NEAREST: SEPTIC TANK S ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRI LTURE WEL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T of Casing Specifications n Public 1-1 Other J___Tl delta DepX, .I deal `�ftf Type of Grout _ I I Irrigation —.Approx. Depth l I East Surfstalled by # _ Repair Work Done ❑ Type of Pump N.P. State Work one _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted it public sewer is available within 200 feet.) r (� 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 (1 SEPTIC TANK ❑ Type/Mfg Capacity No: Compartments V' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:--- Well------ — -Foundation--- - Property-Line LEACHING LINE: ❑ No. & Length of lines Total length/size FILTER BED _ ❑ Distance to nearest: Well Foundation Property Line y SEEPAGE PITS l I Depth Size —� -Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ , 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. it 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 for all requi d inspections. Complete drawing on reverse side. Signed n C.- Title: Date: fJX FOR DEPARTMENT USE ONLY Application Accepted byn� �l�amd(t Date A a t / Pit or Grout Inspection by 11 Date Final Inspection by Date le Additional Comments: !Q 21—' e T 1 rN5 C7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 L7 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 (FEE AMOUNT/DUUfE� AMOUNT REMITTED SCK R RECEI / 4-25 VYED BY �DATE PERMIT'NO. +.EH13241REV.riNs) 3S "v /� � / ' s EH 1 a