86-1406 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT. SAN JOAQUIN LOCAL.-HEALTH DISTRICT C76'01 E. HAZELTON 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.TtQ 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 -��//�� City ( � �" ?L Lot Size s X/�u PM '"Ovvner's NameAddress S Z_I ! Phone /' h Contractor ddress / License l... Phone TYPE OF WELL/PUMP:. NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN AL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL INT ED.USE TYPE OWWtLL_._.. PA08LEMAREA... CONSTRUCTION _r__... 1CATIONS ❑ Industrial ; en Bottom ❑ Manteca Dia. xcavatiori Dia ofWall Casing {- r ❑ Domestic/Private ❑ Gravel Pac Trac Type of Casing Specifications 1 ❑ Public I ❑ Other Delta h of Grout Seal' Type of Grout r ❑ Irrigation _Ap (, epth Cl Eastern Surface Seal n --� 1 Repair Work Done ❑ of PUMP H.P. State Work s_ Welf Destruction J!t] Well piame;'eY '`" Sealing Material flop 50'1 f r _ ;. . Depth "c Filler MdterjIJABeloL, TYPE OF SEPTIgWORK. NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer`is available within 200 feet;) . . Installation will serve: Residence Commercial Other 2 ; Number of living units: Number of bedrooms 7� I .i I Character ofsoil to a depth of$feet: Water table depth f SEPTIC TANK ❑ Type/Mfg � Ca El pacity //Z —J- No. Compartment ) PKG. TREATMENT PLT. I + I s ofD IMethod Ditance4o-newesu____yell-" U _(foundation--_ Proa rtYLiR / I LEACHING LINE� No. & Length of lines e� g — Total length/size }.. . ..: FILTER BED - ._.,..I p .Distance to nearest; Well NUNQ Foundation Pro S. "t party Line �', ; SEEPAGE PITS i. ❑L Depth i Size Number , S.LIMPS, ,. .❑ Distahee'to 1pearest: Well u nt Foundations_ Property Line s ;f DISPOSAL PONDS i ❑ r t } w.I hereby certify that I have prepared this application nd that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations,of the San Joaquin Local Healjh_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 sljall not employ any persoq in such manner as to become subject to;workman's compensation laws of California."Contractors hiring or sub contracting signature t certifies the followi�lg:"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 must call for all required inspections. Complete drawing on reverse side. r t Signed Title: ✓( � '''' Pate: 1 I f' OR DEPARTMENT USE ONLY -_.__.... - Application Accep e y _ ` O } E Date yea Pit or Grout Inspe tion by 0 . ate f! /�Ainal Inspection ate r t!9 _,. ... _, _ _.._...---..,., ....__.__....r._,..�,..:_,._..:,....:.__.....�.,... ..-. ._._.._•_-._ Q,Stk_.468-6781 ❑ Lodi 3693621 ❑ Manteca 873-7104 ❑ Tracy 835-6385 ` j'Applicant_Return'all copies'to: Environmental Health Permit/Services 1601'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FBE_ AMOUNT DUE AMOUNT REMITTED' CK AF - INFO CASH RECEIVED BY i DATE PERIMIT NO.~ } EH,13-24(REV.T 7 A