87-3671 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQIUIN LOCAL HEALTH DISTRICT ` ' K 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 x PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED ii (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 �j /Y•I C�?JrC(f (� City�7 =-r'� Lot Size2Z9CdPM 7 Owner's Name6)h?�f Address S1 �6;-,J Phone�3 /79 f Contractor Address Tft71� Lkicense No. Phone TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' ' ""• DISPOSAL FLD:"" "` PROP. LINE_ FOUNDATION AGRICULTURE WELL OTHER WELL_.. _— PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION 5 ATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Excavation o Dia. of Well Casing ❑ Domestic/Private ❑IGfavel Pack ❑ Tracy Type of Casing Specifications ❑ Public 'other elta Depth of Grout Seal Type of Grout - I Irrigation Depth l I Eastern Surface Seal Installed by Repair Work Dane ype of Pump H.P. State Work Done } Well Des n ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.I REPAIR/ADDITION I I DESTRUCTION ) INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other .a Number of living units: t Number of bedrooms psn. :' € '► j Character of soil to a depth of 3 feet: r —'.Water table depth P SEPTIC TANK ❑Type/Mfg Capacity_-, *VNo. Compartments PKG. TREATMENT PLT. ❑ � tv � � Method of Disposal ♦'Distance to nearest: Well Foundation 'r Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to_nearest: Well Foundation + Property Line f SEEPAGE PITS i I Depth s Size _ Numberw { SUMPS Cl Distance to nearest`"—Well'" *' Foundation Property Line ' DISPOSAL PONDS ❑ ` 1 I hereby certify that I have prepared this application and that the work will he done in accordance With San Joaquin county ordinances, state laws, and rules and regulations of the Sart Joaquin Local Health District. IV Home owner or licensed agent's signature certifies the following:0-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 I certifies the h : "I certify that in the performance of the work for which this permit is issued, i shLil employ persons subject to workman's compensa- I tion laws Califor a." - t j The a cant required in ctions. plete rawing on reverse side. f Signed D Title: Date: 7/7,09 7 e FOR DEPARTMENT USE ONLY rt Application Accepted by * Date L� rea Pit or Grout Inspection br��J Date Final Inspection by Date / i Additional Comments: 7 -- _ 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-63$5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'ND. . EH 1 -241REV.1/x51 ; EH 1429