88-1080 - Laserfiche WebLink

Home Browse Search

r \A C I ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ! ` (f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 4'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. Job Address 7 •- �r[/ �li�� City { ,Lot Size PM Y36Owner's Name IACA�r Address O w' ' d� ~ Phone — 3 Contractor J� Address �22 /**icense No. 6 /3 Phone 1 TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR (7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�,f,., fPROP. LINE 4✓ FOUNDATION AGRICULTURE WELL OTHER WELL c� / PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS �. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private X Gravel Pack 10 Tracy Type of Casing� V(f, Specifications FI Public ❑ Other 71 Delta Depth of Grout Seal ` Type of rout 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 N TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION f I (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 _ No. Compartments 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 ' SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 DjMrict. 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 applicant st call for all requir9l inspections. Complete drawing on r erse sidfi- Signed X Title: Date: 4-2(,1469 FOR DET USE ONLY 7 Application Accepted by J Date 9T�_ Area �J Pit or rot Inspection by Date �J Z Final Inspection by Q' JD�e Additional Comments: ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 IT, Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952pl.FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PE +.EH13-24 1REV.i i N a) EH 14.28 r r