SU0014565 (2) - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAr JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V. (Complete in Triplicate) V Application is herety made to the San Joaquin Local Health District for a permit to construct and/or install the work n•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�6,puletions of the San Joaquin Local Health District. Inh Arldress AP/C r07 rJtfCs .JfAY. OVA7- % i Af— &®itv / PAq/ I,,, ;i,.1177 -90 M PIU i nereoy ceruty 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 applicanjpustpl I'all regyj/d gApections. Complete drawing on reverse side. , Signed X �st�A��I ill _ / 1l Title: COMA- Date: l FOR DEPARTMENT USE ONLY Application Accepted by Date 4-,f O a Area rj Pit or Grout Inspection by c -t,) Date ' �' 0 Q Final Inspection by Additional Comments: %-J ❑ Stk 466-6781 ❑ Lodi 1 ❑ 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 . EH 13-24 (REV. I 1 e 5 EH 14-28 Date FEE INFO AMOUNT DUE Owner's Name �1/��)W40D4 �e'"ress { , �,� fLllp Phone • Contractor i;4cc �o DQWA%?�-Address dw- No. Phone ' TYPE OF WELL/PUMP: NEW WELL WELL REPLACYAENT ❑ DESTRUCTION ❑ INSTALLATION ❑ SYSTEM REPAIR ❑_ OTHER El _PUMP _ _ DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLO PROP. LINE FITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑� ❑ 0 n Bottom ❑� Manteca Dia. of Well Excavation Dia. of Well Casing �Industrial ETDomestic/Private �'C;ravel Pack FI- racy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal /(x% I/ Type of Grou ❑ Irrigation '0 D f�_�Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P;- - ---- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ~Y Filler Material (Below 501 TYPE OF SEPT INSTALLATIQN ❑ RfPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is - available within 200 feet.) Installation will serve: Residence Commercial _ Other _ Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i nereoy ceruty 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 applicanjpustpl I'all regyj/d gApections. Complete drawing on reverse side. , Signed X �st�A��I ill _ / 1l Title: COMA- Date: l FOR DEPARTMENT USE ONLY Application Accepted by Date 4-,f O a Area rj Pit or Grout Inspection by c -t,) Date ' �' 0 Q Final Inspection by Additional Comments: %-J ❑ Stk 466-6781 ❑ Lodi 1 ❑ 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 . EH 13-24 (REV. I 1 e 5 EH 14-28 Date FEE INFO AMOUNT DUE AMOUNT RE/MITTED CASH RECEIVED BY DATE PERMIT' N0. U 1/Z , c� v 9A I S� 1