88-2467 - Laserfiche WebLink

Home Browse Search

[ I APPLICATION FOR PERMIT I 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �f � Job Address�y /+ 2 1 640 WOAD City Lot Size 'J e�M Owner's Na � �"��Ffddr`ess , ! /Af1/�J�/lP�fi3b Phone ��e J l � IddressPU, (�p &A� License N 290 Phone �VY TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Pdustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ ublic ❑ Other ElDelta Depth of Grout Seal Type of Grout Irrigation —Approx. De h ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �� t available within 200 feet.) Installation�l e: Residence' Commercial—"Other Number of living units: umber of bedrooms �{a Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` ; . ' IIt Method of Disposal Distance to nearest: f�Well E Foundation Property Line } LEACHING LINE ❑ No. & Length of lines I`o Total length/siz FILTER BED ❑ Distance to nearest: well Foundation Property Line " SEEPAGE PITS ❑ Depth Size r Number SUMPS ❑ Distance to nearest: Well - ' Foundation Property Line (� DISPOSAL PONDS ❑ 5-7 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 I rules and regulations of the San Joaquin Local Health District. `11 VV 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 Q 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 Ca� nla." •. w_ _. ' r: The applica m t call for all required ins io Co ete drawing aCl side. Signed Title: , Dat FOR DEPARTMENT USE ONLY Application Accepted by Date�y— Area Pit or Grout Inspection by Date Final Inspection by Date 11_414 Additional Comments: U ❑ Stk 466-6781 ❑ Lodi 369-36210 anteca 823-7104 .❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Heath Permit I Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 e INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. CASH +EH 1324[REV.F/B5Y3� EH 1428 - i