88-2135 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA , Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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 AddressI1✓� Citys�z� Al Lot Size PM JIK-� Owner's Name �]�CJi '' kLlV Idress crAm Phone 41�a Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CY DESTRUCTION ❑ PUMP 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing '� Specifications ❑ Public Cl Other ❑ Delta ,. Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth I I'Eastern Surface Seal Installed by \{. Repair Work Done ❑ Type of Pump f H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below"501) TYPE OF SEPTIC WORK: NEW INSTALLATION I1a REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is r { µ available within 200 feet.) Installation will serve: Residence— Commercial_ Otherr ' Number of living units: Number of bedrooms ,` a � Character of soil to a depth of 3 feet: - f. ` ' Water table depth SEPTIC TANK_ ❑ T e/Mf r Yp 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal a r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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. 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 applicant must call for all squired inspections. Complete drawing on reverse side. Q Signed X Title: /�i�1—]��/� Date: p r � f - DEPARTMENT USE ONLY Application Accepted byF �_�w Date �� Area CIO Pit or Grout Inspection by Date Final Inspection by Date 00 Additional Commen ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 INFO /AMOUNT AMOUNT REMITTED C KSH RECEIVED By DATE PERMIT'NO. ..EH113-241aEV.1/451 ;Z C.� 4 /�_Qt'/ .7� EH 4.26 V� J [1 ` G �[ -15,