88-3351 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT VSO SAN JOAQUIN LOCAL HEALTH DIST4MCT F 1601 E. HAZE T ON AVE., STOCKTON, CA Iv Telephone (209) 466-6781 PERMIT EXPIRES 7 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 1 Local Health District. c .i Lidress ✓ s+ City-0� Lot Size ��x �� PM Address Zd1 � PhoneAddress License No. Phone LL/PUMP: NEW WELL'❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION;L] SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel ❑ Tracy Type of Casing Specifications 1-1 Public t er n Delta Depth of Grout Seal Type of Grout I 1 Irrigation _,Approx. Depth l 1 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 lSelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION if.) REPAIR/ADDITION I I DESTRUCTIO CjNo septic system permitted if public sewer is available within 200 feet.I 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 ( p PKG. TREATMENT PLT. ❑ Method of Disposal V� 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 SEEPAGE PITS 1 1 Depth Sire Number SUMPS L-1 Distance to nearest:, Well Foundation Property Line I 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, andt 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." n he applicant st call for all require nspections.,Complete drawing on reverse side. Si ned . _( Title: Date: FOR DEPARTMENT USE ONLY ` f Application Accepted by _- �CIf _ Date 2 IV ?Area Pit or Grout Inspection by to_._._.._.� Final tion by Date l;"C> Additional Comments: it ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-71104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY t DATE PERMIT'NNO. +.EH14-241REY.iin5J � /�'.& -5 ` /� % 1 21 2G l.�Q,� EH 14-28 f,.._._. !✓i r� Gf (J fJ [J` n