88-2437 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J (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. Job Address • City Lot Size M 1 J Owner's Name !`Address 7 2 5 0:rr)c?f -501 Dd Phone �r / tY. 4 Ikontractor t"_mi,!ar Address 51-- er , License No.. Phone 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM R AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULT E W L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL MMaterial EA C TRUCTION SPECIFICATIONS `) ❑ Industrial 0 Open Bottom ia. o Well Excavation Dia. of Well Casing ❑ Domesticl Private ❑ Gravel Pack ClType of sing Specifications ❑ Public n Other Depth of G ut Seal Type of Grout I I Irrigation --Approx. DepthEastSurface Saal I tailed by _ Repair Work Done ❑ Type of Pump State Work Done Well Destruction ❑ Well Diametering Material (top 50'1 Depth r Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION E I DESTRUCTIO (No 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 1X11 I I acit No. Compartments (� PKG. TREATMENT PLT. ElL rpf{ Method of Disposal Nil Distance to nearest r ll[) I a.VMR. 1dn`-` WiIhOU Property Line e LEACHING LINE ❑ No. & Length of fines1 11 'rlength/size FILTER BED ❑ Distance to nearestby rf�uironmi-7 liv a o ioILI n I LAOProperty Line SEEPAGE PITS I 1 Depth Size Number SUMPS '❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 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." The applicant must call for all uir inspections. Complete drawing on reverse side. �igned X' Title: /nom Date: 6;1 OR P.ARTMENT USE ONLY t� Application Accepted by [ AA � Date r �`��^'� y Area Pit or Grout Inspection by Date_ Final Inspection by Date Additional Comments: �1/� �y�✓ �! ✓4{ 1// � ___� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental'Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE Q PERMII1 NO. +.EH 1124(REV.t/N5) EH 14.26 Jf