88-2107 - Laserfiche WebLink

Home Browse Search

t APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E'%HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 if 'PERMIT EXPIRES TYEAR FROM DATE ISSUED 1 . _ (Complete in Triplicate) i 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 1s 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. f Job Address $3 #E V� Citys � Lot Size PM f "1 Owner's Name nob Address Phone �y I Contra or 1 �--r_ �Address Alicense No. 0� Phone TYPE OF WELL/PUMP-. NEW-WELL-'U"'" `"" "WELL REPI=ACEMENT'0 —DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ., FOUNDATION., -� AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL - .PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial "s ❑ Open Bottom © Manteca--- Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack - ---❑..Tracy Type of Casing Specifications ❑ Public Cl Other j fl Delta Depth of Grout Seal Type of Grout _ I I Irrigation _-Approx~'Depth—I-] Eastern—Surface-Seal-installedby'-- Repair Work Done ❑ Type of Pump H,P. State Work Done _ t Well Destruction ❑ Well Diameter Sealing Material (top 50'I ' 1 Filler Material (Below Depth! ---- � f TYPE OF SEPTIC WORK: NEW INSTALLATION [.] REPAIR/ADDITION ESTRUCTION I I (No septic system permitted if public sewer is available within-200 feet.I +✓' t Installation will serve:w,Re rdencemercial- _Other__ Number of living units: -7SNumber of b rooms { Character of soil to a,depth of 3 feet: w Water table depth SEPTIC TANK f ❑ Type/Mfg' Capacity No. Compartments PKG. TREATMENT PLT. 0 ,-3t.. t Method of Disposal Distance to neatest: Well FoundationProperty Linefly "' r LEACHING LINE r C�--P}o: & Length of linesTotal length/size FILTER BED ❑ Distance to nearest: Well Foundation �operty Line.- _ SEEPAGE PITS depth Size Number f f SUMPS " L1.7 Distance to nearest: Well._ Foundation—�- - .!Property DISPOSAL PONDS / l I hereby certify that I h}ave prepared this application and that the work willbe done in ccordance with San Joaquin county ordinances, state laws, and rules and regulations of'the"Seri Joaquin Local Health District. 'o Home owner or licensed agent's signature certifies the following; "f certify thatin the performance of the work for which this permit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifie he following: I certify that in the performance of the- ow rk,for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o aGfornia:r } E The applicant st call for it quir inspe ns.ioC m wing-on r verse sid 1 74 I ills: Date: Signe E i-' k, FOR D R7M N OSE ONLY b Application Accepted by ' Date r d t3 Area _ Pit or Grout Inspection by Date Final Inspection by �/ `f-f/ Date � �2 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ 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 AMOUNT DUE,1 AMOUNT REMITTED CLASH RECEIVED BY DATE PERMIT'NO. INFO EH 13-24-(R£V.1/H 5) `10. p EH 14-26