88-3206 - 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. City �{-,61(a ` ,-Lot size K 2� 6 PM o Job Address �^� �.^r Address -� �Dt: J►°�'r�S CA_Phone Owner's Name -,�' � 1� Contractor Address ry Y�r License No. V Phone_ TYPE OF ELL PUMP: NEW WELL ❑ WELL REPLACEMENT LI DESTRUCTION C1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout — FI Public f--1 Other FI Delta Depth of Grout Seal I k Irrigation —Approx. Depth I 1 Eastern Surface Seal installed by H P State Work Done Repair Work Done ❑ Type of Pump Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION l l availableseptic within 200 feet.) if public sewer is 1 installation will serve: Residence_X_ Commercial _ Other _� Number of living units: J_ Number of bedrooms_ 3 Water table depth oC Character of soil to a depth of 3 feet: T e/Mf �o^'c�� Capacity `., No. Compartments SEPTIC TANK YP 9 Method of Disposal PKG. TREATMENT PLT.-0 � E,4 timid S� Distance to nearest: Well 5 1 Foundation Property Line ��' LEACHING LINE El No. length/size No. & Length of lines r FILTER BED ❑ Distance to nearest: Well SSf Foundation a �'{ Property Line SEEPAGE PITS D°r Depth S Size �6 ! Number SUMPS ❑ Distance to nearest: Well 1 00 eFoundation Property Line n 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, 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 became 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, !shall employ persons subject to workman's compensa- tion laws of California." The:pplic7an st a for al r yired ins tions. Complete drawing on reverse side.Signd X Title: 0 W f J eDate: d FOR DEPARTMENT USE ONLY / ,Q Date b v Area Application Accepted by � � Data Final Inspection by Date V IJ Pit or Grout Inspection by _ Additional Comments: -P—VZ_ / 577 ,576 ❑ 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. Box 2009, Silk., CA 95201 CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO + EH13-24WEV.t/Kto 70 00 0— 70 00 1-1 EH 14-28