88-1688 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA P Ay 1jV1E ED Telephone {209) 46f3-6781 REC PERMIT EXPIRES V YEAR FROM DATE ISSUED U ,g (Complete in Triplicate) , - �uN made to the San Joaquin Local Health District for a permit to construct and/or nstlallll the Rwrork herein descc�r a Thi��abU &''s Application is hereby twvkvs �T�S p made in compliance with San Joaquin County Ordinance Na.549 forrsewage or No. 1862 far we I p p ^AA Local Health District: , City ' f° Lot Size PM Job Address' z Z ' 1. Phone ' %1.3 I ^`„ ,j .._ _ Address Owner's Name Contractor �1'v Address 525, 0 Q, f'. LQ icense No. � Phone S�� �- WELL REPLACEMENT ❑ DE5I RUCTION ❑ TYPE OF WELL/PUMP: ELL ; SYSTEM REPAIR ❑ OTHER ❑ I PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK _�?�'E%- SEWER.LINES _:__ ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - .. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia: of Well Excavation � �/ Dia. of Well Casing ❑ Industrial EJ Open Bottom ❑ Manteca T e of Casin Specifications Domestic/Private j�4 Gravel Pack Tracy yp Casing______e Type of Gr ut . + F] Public 1 1.Other F1 Delta Depth of Grout Seal Type of G �- r l I Irrigation Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H P State Work Done I Well Destruction ❑ Weil Diameter Sealing Material Itop 50'1 ial (Below 50'I Depth Filler Mater I TYPE OF SEPTIC WORK: NEW INSTALLATION i]_ REPAIRIADDITION l I DESTRUCTION I I allo septi cystithin m rented if public sewer is I Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Water table depth f Character of soil to a dept.h of 3 feet: Capacity No. Compartments SEPTIC TANK Q' Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ !_ Distance to nearest: Well Foundation Property Line J F LEACHING LINE ❑. No. & Length of lines Total length/size FILTER BED � ❑' Distance to nearest: Well �- Foundation Property Line r SEEPAGE PITS i I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property tine _ - - - - 1 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 Diltrict. 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." Contractors hiring or sub-contracting signature certifies the fallowing:"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 Calif rnia." The applicant m t call for all req*ns7lons. drawing an r er side. Signed X Title:, ' Date: R C}EP IN ENT USE ONLY Area Application Accepted byPit Grout spection b _ = Final Inspection by Date Additional Comments: Y ❑�Lodi 369-3621 �❑ Manteca 823-7104 ❑ Tracy 835-6385 ❑ Stk 466-6781 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE CK RECEIVED BY DATE PERMIT AMOUNT DUE: AMOUNT REMITTED r.EH 13-24 IREV.s K 51 EH 14-28 VV .