88-948 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. I City Size ?110 PM Job Address jW�lC l✓ RD Lot tr Owner's Name VA& CLAQSMI Address Phone 'y ,Z y�U�G _ Address "'License No. cad, 0 Phone Contractor TYPE OF WELL/PUMP.:„-.. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Z PUMP.INSTALLATION © SYSTEM REPAIR ❑. OTHER ❑ 5 DISTANCE,TO NEAREST:-SEPTIC TANK SEWER.LIN ESL -.DISPOSAL Fl-D. 'PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL � PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `! I a ' F-1IndustrialClOpen Bottom ❑ Manteca Dia. of Well Excavation / --•Dia. of Well Casing s f ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type oYCasing Y'' * Specifications M Public [7 Other Ll Delta t . Depth of Grout Seal Type of Grout 11 Irrigation N Approx. Depth { I I Eastern Surface Seal Installed by j Repair Workrpone -.❑ Type-of Pump t H.P. y --State Work Done Well Destruction- ❑'> Well Diameter i' Sealing Material (top 501 Depth 1. Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence car Cdlmmerciaj_` Other Number of living units: Number o1 bl#d-FUUMS Character of soil to a depth of 3 feet: eg, Water table depth SEPTIC TANK ❑ Type/Mfg r Capacity p_AtNo. Compartments r PKG. TREATMENT PLT. ❑ ..: °9� �� Method of Disposal F Distance to nearest: Well;*'6 Foundation � Property Line LEACHING LINE No. & Length of lines. C Total length/size FILTER BED ❑ Distance to nearest: Well f/C3nFFoundation Property Line x SEEPAGE PITS I Depth 3 Size �� _ Number i SUMPS Distance to nearest: loeWell /°'�Foundatiorr Property Line �D DISPOSAL PONDS ❑ I hereby certify that 1,have,prepared this application andathaf the work will be done in accordance with San Joaquin county ordinances, state laws, and �l rules and regulations ot.the San Joaquin Local Health Distirict. ` Home owner or licensed agent's signature certifies the'following: "l 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." / ! r d# The applicant must call for Orequir inspections Complete drawing on reverse side. sr Signed X Title: !0 -u Date: a OR A'RTMENT USE ONLY �'FApplication Accepted by Date 7 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO CASH ' ♦ EH13-24(REV.4 N 51.. _.. -eP ._ y.,.,....._.. .`—..� ..:. ,,. -_ '�` "' �.;'''.a,�1 ,� r..x.� .t..•.. _ .�/ _ - .. �.,� ry� .. ,,.,,_ ...,, EH 14.26