88-1265 - Laserfiche WebLink

Home Browse Search

' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`TON AVE., STOCKTON, CA 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i Job Address :lo ZZ �f,�lJ& �� City Lot Size PM Owner's Name Address Phone C � a.d �-� Contractor NS Address � CJ/tiG��icense NoAZF8�e/ Phone — f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION v /e�4RC I/FAY57EM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public I.1 Other {71 Delta Depth of Grout Seal `= Type of Grout I i Irrigation _Approx. Depth i I Eastern T Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. I State Work Done AEEGlrti/c � FrjU Well Destruction ❑ Well Diameter Sealing Material (top 50') i...,l•( �/7� Depth Filler Material IBolow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION 1.1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200•f6et.1 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 4p/ SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments v PKC. TREATMENT PLT. ❑ �®-, - ----Method of Disposal Distance to nearest: WellFoundation Property Line i C LEACHING LINE ❑ No. & Length of lines Total length/size T FILTER BED El Distance to nearest: Well .� Foundation Property-Linek�-- 0 t SEEPAGE PITS 11 Depth Size Number ;�. SUMPS Cl Distance to nearest: Well Foundation Propeoltine ,.. DISPOSAL PONDS ❑ � -,i ` �;'Iiuq-'c t=E:,,.l �'�•� � N 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. F ENVIP!!,/.viLl� IAL 1 EALTH Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whicht ll-is-a�ii i>t. sld- issued, I shall not s..t. s ,,.. fi 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 w_hich this,permit-is issued,Tshall employ persons subject to workman's compensa- tion laws of California." The applicant t II requi ctions. Complete drawing on r er ida. Signed'X. Title: bate: r FOR DEP TMENT USE ONLY �� Application Accepted by Dat Area 616 _ Pit or Grout Inspection by Date Final Inspection by Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 j Applicant - Return all copies to: Envirorimental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk:, CA 95201FEE t INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. ♦ EH 13-24 IREV.1 n 51 EH 14-26 Q - � a g -.' i - - i