84-1373 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT $ 4 SAN JOAQUIN LOCAL HEALTH DISTRICT U 1601 E.-HAZE4TON -AVE,, STOCKTON, CA pC.T 419PA Telephone (209)'466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED �pAQU �pld �IN (Complete in Triplicate) Q - 0yo - 74 FskhT� �TRih'T Applic n y ma eta 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �.A %Ir� 11�L1Y( �:.. G/`?fQ.uti. o PM Job Address AMOUNT DUE AMOUNT REMITTEDCASH �/Id Owner's Nam ' Address �GH u Y Phone Z .j 162-373 Phone Contractor's Name dh icense No. TYPE OF WELL/PUMP: ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 9---- SYSTEM REPAIR F.� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑� Industrial ED Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l�'Dond�mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout „ ❑ Irrigation --Approx. Depth ❑ 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 (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ..DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) 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 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 SEEPAGE PITS 0• Depth Size Number SUMPS Elm Distance to nearest: Well Foundation Property Line n1CcnQA1 antinc -1 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. 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 pe ch manner as to become subject to workman's compensation laws of California."Contractor's ia." Ctractor'hiring or sub -contracting signature certifies the lowing: "I riify that in the performan f the work for which this permit is issued, I shall�empioy persons subject to workman's compensa- tion laws o California." w The appli nt must call all req ' Comp/ a drawing on reverse Signed X u Title: Date: �� Z FOR DEPARTMENT USE ONLY / Application Accepted by Date 161-0YArea Pit or Grout Inspection by - F Date Final Inspection by Date% Addificinal Comments: ❑ Stk,0466-6781--" - ❑ 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 + EH 1324 (REV. 101831 EH W26 FEE INFO AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT `NO. L 6`0 PP [ 0 Z14—R-f gni-1373