88-368 - Laserfiche WebLink

Home Browse Search

APPLICATION'-FOR PERMIT - f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Coui ty 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 S'�SO l79RI' 7PHS.4 .` City, �'`� - Lot Size PM Owner's Name Address x Phone i Address Contractor ® License No.,512-1Phone -397. TYPE OF WELL/PUMP: NEW WELL_.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 17 DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE T FOUNDATIONS s AGRICULTURE WELL WELL {PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST ION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing && ❑ Domestic/Private # -❑ Grave! Packr— El Tracy Type of Casing Specifications 1-1 Public Cl Other I Cl a Depth of Grout Seal Type of Grout I 1 Irrigation .._ -Approx. Dept I Eastern Surface Seal Installed by j Repair Work Done D Type of Pu H.P. State Work Done ; Well Destruction ❑ Well Diameter Sealing Materia! (top 501 t 1 Depth { Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIOK.-;1I REPAIR/ADDITION (.1 DESTRUCTION I I (No septic system permitted if public sewer is p�T S available within 200 feet.l Installation will serve.: -Residence Commercial_ Other Number of living units: 4— Number of bedrooms Character of soil to a depth of 3 feet:, 1 : Z-AIV Water Itable depth F SEPTIC TANK ❑ Type/Mfg rv,��,.iG- Capacity No. Compartments j PKG. TREATMENT-PLT'❑ L Method-of Disposal 11 - r Distance tot near7est: Well Foundation Property Line t / LEACHING LINE No. & Length of.line`s( ' Total length/size 412 / ,Z, ( ' ( FILTER BED ❑ Distance.to dearest: 1 Weil Foundation /O r Prop erty.Line /d ri � Q SEEPAGE PITSi Depth �^ ,1- . -YSize '�. 3 rr I Number SUMPS Lli Distance to nearest: Well �0� �sr Foundation �� r Property Line /d - DISPOSAL PONDS ❑' / I hereby certify that I have prepared,thiss-applibation and tRat the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 becor<ne subjectIto workman's compensation laws of California." Contractor's hiring of 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 required ins ctions."Coete drawing on reverse side. �i Signed X h._ Title: Date: Z�y4 -9� # F R DEPARTMENT USE ONLY Application Accepted by _Date �-�y Area Pit or Grout Inspection by Data Final Inspection by Date ! Additional Comments: E O ap i fel 1+�t7s' - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 r FEE AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMIT NO. INFO ++.EH 13-241REV.iiNs7 C� �. _��I �Ip� EH I4-28 li