88-1585 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. O YdA- d� City Z Lot Size G PM Job Address —f- _ C Owner's Name XgAe Address r4� Phone .._....-.._.,...-- Contractor c V4449'�. Address Pa, /!Llff!VTdA- License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ C/SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER L,,NE� DISPOSAL FLD. PROP. LINE FOUNDATION GtIGGLYURE WE L OTHER WELL—PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS { ❑ Industrial ❑ Open Bottom ❑ Ma ¢ Di . f Well Excavation Dia. of We Casing D DomesticlPrivat7 ED Gravel Pack racy ; ,- Type of ng Specifications f I`1 Public ❑ Other ❑ Delta Depth of Grout al Type of Grout I I Irrigation ,,', Appr :'Depth Jul I'Eastern t Surface Seal Installe y I Repair Work Done ❑ Type of Pump H.P. State Work Done_ F Well Destruction #❑ Well Diameter Sealing Material (top 501 { € Depth Filler Material (Below 50')'' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I'] DESTRUCTON i I (No septic.system permitted if public sewer is "%available within 300 feet.) Installation will serve: Residence_L_ Commercial_ Other j r ^- ` •! ' Number of living units: --f— Number of bedrooms. Character of soil to a depth of 3 feet: ADbUrn 't? '1Water table depth SEPTIC TANK ❑ Type/Mfg Py4rL.- - Capacity �" No. Compartments PKG. TREATMENT PLT. ❑ z Method of D-ispcisal Distance to nearest: Well - Foundation Property line LEACHING LINE iNo.,& Length of lines 'Total length/size ; FILTER BED' ❑ Distance to nearest: w6il '' "` Foundation" f Property Line {" SEEPAGE PIS I I pepth 1L4Sizet «� Number SUMPS "" ``Q "Distance to nearest. - Well tFoundation •fit? Property-Line 1 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin coun'ty."ii inances, 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 compensaflon laws of California." Contractor's hiring or sub-contracting signature 1 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." Thea plicant must call for.all re wired ink ► p � q. pectigns. Complete drawing on'-reverse side.:.; � Signed X �� Title: r ' , Date: t:;;; r7 � OR DEPARTMENT USE ONLY t t 1 � n (0 _ q j Application Accepted by +N i Date FCIZ71O Area I S i Pit or Grout.Inspection by Date Final Inspection by j Date 4 1 9Additional Comments: ❑ Stk 466=6781 --•❑-Lodi--•369- 621 ❑Manteca 823 710A ❑ Tracy 835 6385 r Applica 1 Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO -FEE.- -AMOUNT DUE— -AVO.UNT`REMITTED CASH _ ~RECEIVED-BY" DATE— PERMIT_N6_ K + EH13-24(REV.1/N sl D EH t4-2B {