88-3116 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 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 iRegulations of the San Joaquin Local Health District. UJ R�f�L o Job Address i !�N � D City '91� Lot Size PM Owner's Name Ross �Z L%-J"J Address `-" IMC Phone Contractor ► + ��RG} Address '�� 1 v OT-TGAJ Fy'rLLicense No.IV-V'(4 Phone 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 WELLi 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 I r D Public 171Other 171Delta Depth"of Grout Seal Type of Grout I IIrrigation _--Approx. Depth t I Eastern Surface Seal Installed by - Re.pair Work Done ❑ Type of Pump H.P. State Work Done f Weil Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth filler Material (Below 50') TYPE OF SEPTIC WORK: NEW-INSTAL-L-A-TION ---REPAIR/ADDITION l I DESTRUCTION { I Wo septic system permitted if public sewer is i available within 200 feet.i I Installation will serve: Residence Commercial Other Number of living units: I/ Number9f,bedwocris� W Character of soil to a depth of 3 feet: t - VolWater table depth I -SEPTIC TANK ❑ Type%Mfg` k ii-" - f Capacity 1 2`00 No. Compartments PKG. TREATMENT,PLT. ❑ „Method of Disposal Distance to nearest: Well Foundation Property Line q,{t f` LEACHING LINE M---No. & Length of lines _ _ _ O Total_fengtfilsize Ih FILTER BED ❑ Distance to_nearest: . Well Foundation Property Line e I` SEEPAGE PITS I I Depth Siie Number It SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 District. 1-;4 t 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 be me subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the _Te of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." k Thepplicant N for purred ipectians. C#omplate drawing on reverse side. Sign:- Title: 1 F Date: I ! 1 S € .--F _DEPART.MENT:USE-ONLY- w ,�+ p l ..-�? Application Accepted by _ - Data � re - E Pit or Grout Inspection by Date Final,Inspection b Date Additional Comments: �1'ir /I' ��' �f� ��- �Q�O d/J� �� cl+�✓ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 of�� >r� " ` � "'�` ✓� ca -Applicant- Return all copies-to:_Environmental_Heaith_Permit/.Services 1601-.E._Hazalton.Ave.,-P..0—Box 2009,-S4kI-,-CA-95201 . IFEENFO AMOUNT-DUE, ` .,-AMOUNT REMITTED-10 RECEIVED BY DATE PERMITN{0. + EH 13-241REV.t/nsl ''`^7 y' _ T EH 14-26 /G�5J d,p 4