87-1853 - Laserfiche WebLink

Home Browse Search

k j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 9601 E. HAZE T ON AVE., STOCKTON, CA l Telephone (269) 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. F �/ Job Address O Q City 1 � Lot Size PM Owner's Name �R' Addres)50_25_ ;E1 1 Cv�' Phone `(x2 —79:;MP Contractor Address License No. Phone E TYPE OF WELL/PUMP: ,, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 'L) SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION IONS ❑ Industrial ❑"Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel'Pack ❑ Tr Type of Casing Specifications Q M Public I C1 Other] t l Delta Depth of Grout Seal Type of Grout ._. I I lrrigation prox. Depth i I Eastern Surface Seal Installed by _ Repair Work Do Type of Pump H.P. State Work Done r Well D ction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION {.I DESTRUCTION I (No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence� Commercial T Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i 5EPTIC:TANK ❑ Type/Mfg Capacity No. Compartments r 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 I � r I SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ *I hereby certify that I have prepared'!his application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joquin 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." Contractors 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." TDhAapkficant must call for all requirejd in cions. Complete drawing on reverse side. r--� Signed �/ A�7► �� Title: Date: i I )q FOR DEPARTMENT USE ONLY { Application Accepted by v Date 5—n-77 Area � n a Pit or Grout Inspection by ate Final. Inspection by Date )� f Additional Comments I � t ❑ Stk 466-6781 ❑ Lodi 69-3621 ❑ Manteca 823-71OU ❑ 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 AMOUNT REMITTED CK RECEIVED BY DATE PERMIT' 0. ` INFO S F . EH 1 3-24{REV.F/H51 3S r o U 55` I-d`_7 I EH 14-26