88-1648 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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)V Job Address `i Cit �-3 Y Lai Size PM `Owner's Name �1 j�nia J I �� ,y ddress Pho f 4� 6eAt* 4, mrhesaucenseNo.a'—Qfftz Contractor Address - Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SY�Ml ❑ OTHER ODISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE FOUND N AGRICULTU WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS } ❑ Industrial C1 Open Bottom ❑ to Dia. of Well Excavation Dia. of Well Casing S ❑ Domestic/Private ❑ Gravel Pack Cl Tr Type of Casing Specifications ("1 Public ❑ Other elta of Grout Seal r Type of Grout I I Irrigation _ Approx. Depth I i Eastern Surface stalled by Repair Work Done ❑ Type of Pump H.P. tate Work bone Well Destruction ❑ Well Diame Sealing Material (top 50') \ Dept Filler Material (Below 50'1 C� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity J No. Compartments PKC. 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 SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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. 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 a lic n must call for all required inspections. Complete drawing o averse side. r Signe Title: Date• R DEPARTMENT USE ONLY Application Accepted by Z Z Date Area Pit or Grout Inspection by Date Final Inspection by ! Date Additional Comments: L1 1� jl ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Servifcesl1601 E. Hazelton Ave., P.O. Bo 2009, Stk., CA,952 1 "U � Y (�+ Y 11Y l-C•rcFGC ;� �- Gk Gr tom✓ I}� T1��Gl��"L, f Yc4G�vt.� E AMOUNT DUE AMOUNT REMITTED C INFO rte/ CASH RECEIVED BY DATE PERMIT'NO. ♦.EH 13-24[REV.1/x 51 Z�e� �� /' EH 14-28 u 4�d `-'ll (?`[�(f 1�.7(/ /�J