88-231 - 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 of the San Joaquin Local Health District. . I Job Address G 0 � /✓ L s4/if� __ City Lot Size :9 001C PM Owner's Name R01277 Al, 4-65?& & Address __ ' Phone 1 CwtractorALO�fI� 9, a✓.i VPD 'Address 7 M,4,0 License No. Phone ? TYPE OF WELL/PUMP: NEWIWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUM.P_.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C TRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _J_1 Domestic/Private ID Gravel Pack ID Trac Type of Casing Specifications i f'] Public L1 Other n to Depth of Grout Seal Type of Grout V I I Irrigation _..Approx. Dept ' I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Q Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION € I DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) III Installation will serve: -Residence Commercial _ Other p Number of living units: J Number of bedrooms 3 r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg 70 iez_ Capacity 9? No. Compartments -• PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: - Well lde'0' Foundation l0 Property Line -104d LEACHING LINE < No. & Length of lines' -7rTotal length/size FILTER BED ❑ Distance to nearest: Well led 4 Foundation 2-0 z Property Line ,SEEPAGE PITS i Depth __Size $ Fr .Number Z SUMPS ❑ Distance to nearest: Well 1219/ Foundation —lQ4` Property Line -� DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilLbe.done..in-accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 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 subcontracting signature certifies the following: ';I certify that in the performance of the work.-far-which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: Z FOR DEPARTMENT USE ONLY Application Accepted by _ � Date IT Area Pit or Grout Inspection by _1 Date Final Inspection by p Date v Additional Comments: �4 Lo—z6—w,7 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant 623-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMMOOJUNT REMITTED GASH RECEIVED BY DATE QPEprilvlIV NO. + EH 13-24(REV.1/95) V SO. /0 , 00- `O/Z �►�"r� �� a l�e<-�' EH 14-28 i/ !