88-2838 - Laserfiche WebLink

Home Browse Search

Z V, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., 5TOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED G (Complete in,Triplicate) Application is hereby made to ttia 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. Job Address 42?4 y City T�Y Lot Size PM Owner's Name VEPNoN Address ,__// ST Phone Contractor _ Address License No. Phone TYPE OF WELL/PUMP: I� NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL ION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FO�NDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR 6kLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Man a Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications 1-1 Public F1 Ot`her alta Depth of Grout Seal Type of Grout I Irrigation �`Approx. D E I Eastern.,,_,�- urface Seal Installed by _ Repair Work Done`• ❑ Type of H.P. State Work Dane _ r Well Destruction ❑ Wei II:Diameter Sealing Material(top 501 Depth .Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION l 1 DESTRUCTIO (No septic system permitted if public sewer is \ Ince available within 200 feet.) Installation will serve.: ResiCommercial; Other Number of living units: J1 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. ❑ �. � i Method of Disposal Distance to nearest: Well 1'Foundation Property Line LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: Well 'Foundation Property Line .5 SEEPAGE PITS I 1 Depth ' --- Size — --f �` _ Number ,f� SUMPS ❑ Distance to nearest: Well- Foundation Property Line J� 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, and„ rules and regulations of the San Joaquin Local Health Diltrict. Home owner or licensed ag6nt''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.ma4ner 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 Calif rnia.'' h The applicant st call for all required • actions. Complete drawing on reverse side. Signed X ,U Il' Title: Date: \a --z s F -FOR DEPARTMENT USE ONLY ` Application Accepted by M CnG� w _ Date 10 �2 Area 1 Pit or Grout Inspection by �� Date Final Inspection by Date �Q ' Additional Comments: _ )L\] ❑.Stk 466-6781 ❑ Lodi'- 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies 6. Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT-NO. INFO i — .'1'? EH 14-2e