88-1128 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 o the San Joaq in Local Health District. Loaf a Job Address1 Ardif0I D dU' City� A .C1_491 Lot Size ✓4 1706 _ PM -..Owner's Name-CIftfK_-SLUA#ISOK Address. 04_7,?I_ Z VIN L AU, — Phone Contractor's Name [ f l S 0 License IN C g l 1 1 �I g(2 3 b' Phone 2-3 TYPE OF WELL/PUMP: 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`• PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca [Iia. of Well Excavation 1 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other-- _ ❑ Delta � Depth of Grout Seal Type of Grout ❑ Irrigation —1—Approx. Depth ❑ Eastern '� Surface Seal Installed by Repair Work Done ❑ Type of Pump_ H.P. State Work Done r Well Destruction ❑ Well Diambiair I Sealing Material (top 501 Depth '` j Filler Material (Below 501 by TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITIONA DESTRUCTION ❑ (No septic system permitted if public sewer is 6 I r.. I available within 200 feet./ Installation will serve: Residence Commercial___ Other k Number of livingunits: f � Number of bedrooms Character of soil to a depthlof3 feet: S Water table depth SEPTIC TANK i( Type/Mfg ✓�Oi �f>1L P e'rASTCapacity 13-Ca No. Compartments PKG. TREATMENT PLT. ElC 0 Method of Disposal Distance to nearest:, Well 757� Foundation Property Line r' LEACHING LINE No. & Length of lines a— //D Z I IC S Total length/size 9 0 i FILTER BED ❑ Distance to nearest: Well r' J_ Foundation 1� Property Line SEEPAGE PITS ❑ Depth. Size !2__- — ---Number SUMPS ,< Distance to nearest: Wellfi Foundation ZP • Property Line 0 , I DISPOSAL PONDS 1:0 El ! a .`�- % ' 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. i 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 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 m st all for all required inspe ions. Complete drawing on reverse ide. �� 7 � ISigned Title: , Date: FOR DEPARTMENT USE ONLY l t Application Accepted by v — Date — A 21 Area r Prt or Grout Inspection by 1 Date Final inspection by Date l ; !Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 I i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ' +EH13.24 1REV.-10/83) EH 14-26