88-2023 - Laserfiche WebLink

Home Browse Search

21Q`� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. ? {' Job Address v �+ City Lot Size PM Owner's Name 44 ZQdd At4g ress Phone 4 Contractor, dress�/ /� / License fro. -.3.J _Phon� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PI IMP INS LATION O "� SYSTEM REPAIR r OTHER❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ROBLEM ARE ,,CONSTRUCTION SPECIFICATIONS ❑ Industrial 1 ❑ Open Bottom ❑ antec Dia. of Well Excavation °- Dia. of Well Casing ❑ Domestic/Private f ❑ Gravel!Pack ❑ Tr Type of Casirjg t+ ` Specifications 1'1 Public -n Other elta _ Depth of�Grdut Seal _._T,ype of Grout _ I I Irrigation --Approx. Dep l I Eastern!, Surface Seal lristalled by _ Repair Work Done ❑ Type of Pump r5 H.P. ' State Work Done Well Destruction O Well Dia er Sealing Material top 50'1 . Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION. DESTRUCTION i I (No septic system permitted if public sewer is , / ave ble within 200 feet.) Installation will serve: Residence V Commercial_ Other r Number of living units: Number of bedrooms '2— � Character of soil to a depth of 3 feet: i 0 Water table depth SEPTIC TANK ❑ Type/Mfg lCapacityo�ya 00 No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I I Id LEACHING LINE ❑ No. & Leng Total length/size FILTER BED ❑ Distance to nearest: RQundation Property Line # fs E SEEPAGE PITS 11 Depth r ize _ Number SUMPS L] Distance to nearest:"]#well r Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and at the work will be done in accordance with San Joaquin county ordinances, state laws, and t rules and regulations of the San'Joaquin Local Health 1rict. ` 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 applicat must call for all requir inspections. Complete drawing on reverse side. Signed Title: .r�� date: IT F R DEPARTMENT USE ONLY i Application Accepted by Date Area Pit or Grout Inspection by t Date Final Inspection by Date Additional Comments: ` F115/ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hezetton Ave., P.O. Box 2009, Stk., CA 95201 FEECKf IAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY nDATEE�� PERMIT ND. *.EH 13-24 rREV:1/n 51 •Q g�9, YX ` EH 14-28 / "'Ci V _ 1