88-1032 - 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 f S r PERMIT EXPIRES '{'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 Local Health District.[ fi Job Address _J �(1 City Lot Size PM Owner's Name h hl/ /5;['2 ~Z Address �� ' Phone . c 03 q Contractor Address License No. Phone. TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE115LAcEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATI AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM AREA CONSTRUCTIO IFICATIONS ❑ Industrial ❑ Open Bottom (71 Man7Di ell Excavation Dia. of Wel{ Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f Public C) Other ❑ a Dep f Grout Seal Type of Grout _ I i Irrigation _._Approx. De l I Eastern Surface Se nstalled by _ Repair Work Done ❑ Type of P H.P. State Work Done Well Destruction ❑ iameter Sealing Material [tap 50'1 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is vailable 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 9- Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line of LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to.rrn77earest: Well Foundation Property Line SEEPAGE PITS II> ;F Depth t �5� Size� _— Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 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 t call for all required inspections. Complete drawing on reverse side. �T Signed X /�' Title: __C6.,��i�,� /�j/L „„ Date: � QFOR�D•EPARTMENT USE ONLY Application Accepted by O �Cl�iGt/ Date 7 S Area �D Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:0� e/f " C Al f_ ❑ Stk 466-6781 ❑ Lodi 36,cf3fi2l ❑ 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 FEE INFO y`�AMOUNT DUE AMOUNT REMITTED CK'CASH® RECEIVED BY DATE �PE©RMIT-NO. +.EH 13-Z4 IREv.t/H 5) - Jk/1 -.7-71 leul .rEH 14-Zti �-UtJ �--��J`L` 9!(((/// �P� 1 1