88-919 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMITw �() SAN JOAQUIN LOCAL HEALTH DISTRICTe�5 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. .fob Address�f �'"� I,DA7. City Lot Size�� PM r r Owner's NamesSrT Address l 6 Phone 3 0 Contractor : .` ,v r Address 0,%a =.1.: License No. --:P 7691 Phon 't' TY-5- C S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l'l Public n Other FI Delta Depth of Grout Seal Type of Grout . I I Irrigation '_Approx. Depth I I 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 Filler Material (Below 501 9-1 TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REPAIR ODITION I 1 DESTRUCTION l l INo s ti system permitted if public sewer is Q av able within 200 feet.) Installation will serve: Residence_ Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg apacit No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest:' Well Foun tion Property Line G LEACHING LINE ❑ No. & Length of lines Total length/size , j FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS FI Depth 71111-- Numbe W ' SUMPS Ll Distance to nearest: Foundation Pro rty Line DISPOSAL PONDS Cl hereby certify that I have prepared this application and that the work will be done in accordance with San Joa in county ordinances, state laws, and i 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." I The applicant st cal for all quired inspections. Complete drawing on rev rse side. Signed Title: I 121" Date: V*_q ' FDEPARTMENT USE VNLY Application Accepted by D t �!�A"� Area 0— & Pit or Grout Inspection by , L _ Data anal �nspecti/o�n by.} / 'Date/LC2f Additional Comments: 6d( U� L JCC-SSS Pyr4�!CSI �7 r7 1p / ❑ Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy 835-638520 Applicant ices Return all copies to: Environmental Health Permit/ 1601 E. Hazelton Ave., P.qC Bax Stk., CA 95 r, Z 1 e (NFD FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY /DATE PERMIT'NO. +.EH13.24(REV.t/x5) �.�� / �y /(/_ EH 14.26 Jq j— 7 I