88-3257 - 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 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. �l.Job Address y Lot Size PM Owner's Name Address � lw) Phone Contract f 1 Address9. License No.3J?Oa 4l Phon JJ r 02 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ \ OTHER El DISTANCE T0.NEA_REST_: 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 s © Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack w ❑ Tracy Type of Casing _ -Specificationsrl F Public ❑ Other J❑.Delta Depth of Grout Seal Type of Grout Y I I Irrigation --Approx. Depth l ),Eastern. Surface Seal Installed by - S Repair Work Done ❑ Type of Pump H.P.- State Work Done_ S Well Destruction ❑ Well Diameter, Sealing Material ltop 50') f s Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONX RCPAIRIADDITION I I DESTRUCTION I I (No•seblic,s`ystem permitted if public sewer is r r available within 200 fee[.) Installation will serve: Residence Commercial_ Other / Number of living units: --/—' Number of oom __... Character of soil to a depth of 3 feet: Waterftable depth a .• SEPTIC TANK Type/Mfg T Capacity No. Compartments PKG. TREATMENT PLT.❑ - v ., /• , 'i i Method of Di osal Distance to nearest:' Well /OD Foundation.-_ _ Property Line LEACHING LINE No. & Length of lines — f `.Total length/size K a r FILTER BED ❑ Distance to nearest: Well 16 D Foundation. Property Line�__-- / N SEEPAGE PITS ' Depth .S Size _ —t Number Y SUMPS" " L1 Distance to nearest: Well I Od FoundationI f)A_,Pioperty Line S -} 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 Di?;trict. 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 ust call for eq .ed inspections. Complete drawing on reverse si Q Signed Title:_ ��' Date: `� V FOR DEPARTMENT USE ONLY Application Acce d b y Date __ Area it r Grout Inspection by ` ata Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ava., P.D. Box 2009, Stk., CA 95201 I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. r.E!r 13-23 IREV. /n 51 �� - EH ti 3.24 a