88-1466 - 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 !'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 0® `C. City 1131[_% Lot Size PM Owner's Name W x,11 ddress Ty `� �G� _ Phone Contractor _-__� Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC NT ❑ _DESTRUCTION Ll PUMP INSTALLATION ❑ SYST REPAIR LJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ❑ Tr y vne of Casing Specifications ❑ Public Cl Other elta DNpofout Seal Type of Grout _I I Irrigation Approx. Depth t I Eastern SInstalled by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction , ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501 S} TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AODiTION I 1 DESTRUCTION l I Wo septic system permitted it public sewer is O / available within 200 feet.) Installation will serve: Residence X . _ Commercial Other O Number of living units: ._ Number of bedrooms 1 Character of soil to a depth of 3 feet: SC�x�c � 0 cb-`(`n Water table depth TA SEPTIC TANK X Type/Mfg ` s CapacityNo. Compartments PKG. TREATMENT PLT. ❑ k Method of Disposal Distance to nearest: Well l Q Foundation Property Line LEACHING LINE 1K No. & Length of lines _ —�S Total length/size V FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS t I Depth Size s "" _ Number SUMPS X Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di'ktrict. 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." j The applicant must call for all requ' dins c ons. Complete drawing on re a side. Signed X Title: LR2�A f2'�+ Date: U (} _ FOR DEPARTMENT USE ONLY �j�� fP Application Accepted by Date Ll W b[� Area l 3 Pit or Grout Inspection by Date f=inal Inspec'on by Date G Additional Comments: — ❑ Stk 466-6781 L3 Lodi 969-36-21-----D— Manteca 823 7104 ❑ Trac835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haz ton Ave., P.O. Box 2009, Stk., CA 95201 0) IFEEp AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•NO. +.EH 13-24 iREV.1 i n sl 'I�� ✓ 7(! EH 14-28