88-3318 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 r 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 1 made in compliance with San Joaquin Cbunty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. [� ' »$C Job Address + � ! C) ,2„ ,-rrk e:4 2�7 City C Lot Size �' - N PM 1 [ Owner's.Namo �,� _ f� u/�/ti� _rAddress .4 klaah! Phone Contractor A ,V_,y ' /--,P i Address I��7. /�f� +� � . ��' —.,�� —�- �� ! ��;tC�,�. License Na. :Phone 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO 4AREST: SEPTIC-TANK SEWER LINES DISPOSAL FLD. PROP.ILINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I � INTENDED USE TYPE OF:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial j ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack `'i ❑.Tracy Type of Casing_ Specifications Cl Public # ❑ Other0 Delta' Depth-of-Grout-Seal,- - ” Type-of-Grout F i i % F I I Irrigation, i" —Approx. Depth �'LI Eastern Surface Seal Installed by _^ a Re ir�Work Done ❑ Type of'Pum 't p, , Yp P � H•Ps ." 3 State.'Work Done i j^y Weti�bestruction! ❑ Well Diarheter Sealing Material /top 50'I - a Depth . Filler MateriafBel _ `< ! _ TYPE OF SEPTIC'. WORK: NEW INSTALLATION [.] 'REPAIR/ADDITION DESTRUCTION l I IN'sepiic system permitted iF'publiaysewer is available within 200"feet.) InAallation will serve: Residence"_f Commercial Other hr• - ? i '� '' 'ti ; Number of livirig units: �_ LNumber of bedrooms Character of soil to a depth of 3 feet. "` r ' N ] F r Water tMablre,depth- SEPTIC TANK ity o. ompartments 9 Type/Mfg Capac PKG. TREATMENT PLT"pl; f.1 i ' FYI ' t f r ° 'Method of Disposal r t 'I Dista nce,-to nearest: WeflF6undation� Property Lina 1-� /// LEACHING LINE No`•.'& Length of'lines � '- i — Total length/size .. T�... FILTER BED /❑ "'Distance.to nearest: Well" ; .� „�� Faundation45a5'447� Property Line SEEPAGE PITS ? i I Depth Size 1: t SUMPS LI Distance to nearest:_ Well Foundation Property Line i DISPOSAL PONDS ❑ _.. r tf t I hereby certify that I have prepared this application and that the work wilhbe done in accordance with San Joaquin county brdinances,'state laws, and rules and regulations of the San Joaquin Local Health DrItrict. fp Home owner or,licensed agent's signature certifies the following: "I certify thatlin the performance of the work fo'r which this%permit is issued, I shall not I„ employ any person in such manner as to become subiect,to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performah6e of"the wo&forwhich this permit is issued, I shall employ persons subje tt to workman's compensa- tion laws of California.". The applicant must cal(for II tra aired in actions. Complete drawing on reverse side. ' Signed X_- P Title: _72 '" Date: t FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date ` Final Inspection by Date ` I � r Additional Comments: ❑ Stk 466-6701 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 PEE iNFO AMOUNT DUE `� AMOUNT REMITTED CASH CK RECEIVED 8Y DATE .PERMIT-NO. a.EH 1324IREV,'I i n sj- ""---- - -.;, - .. .- - '! -..'._....--..- .�1�1"I'- EH 14-2e 7{y