88-2207 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. g` 7� �j Cite Lot Size PM Job Address v cJ Address ? Phone Owner's Name /dress � - '�`� License No b Ph 7- 7,Z Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ YPE OF WELL/ UMP: NEW WELL ❑ WE PUMP INSTALLATION D - SYSTEM REPAIR ❑ - OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD ROP..LINE FOUNDATION AGRICULTURE WELL. ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO�nteca ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Y Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private0 Gravel P ❑ Tracy -Type of Casing _ Specifications PPublic er ❑ Delta Depth of Grout Seal Type of Grout 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 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW IN IV REPAIR/ADDITION t.I DESTRUCTION available septic system m rmi ted if public sewer is r eet Installation will serve: Residence— Commercial,4 Other 4�-.- E Number of living units: Number of bedrooms , Water table depth Character of soil to a depth of 3 feet: 2 c SEPTIC TANK Type/Mfg Capacity /am No. Compartments r Method of Disposal PKG. TREATMENT PLT. El �z �! �+ Distance to nearest: Well 2� Foundation 15 — Property.Line_5e j LEACHING LINE k( No. & Length of lines Z.�-A 10 L 2= /-1-0 f Total length/size "/ 69 FILTER BED ❑ Distance to nearest: Well-- Foundation Property Line k SEEPAGE PITS f i Depth Size Number SUMPS ❑ 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 accofdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. following: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the 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 Calif nia." The applica t ust call for all requir i pecti ns. mpl to drawing on reverse side. Signed X Title: Date: FOJR DEPARTMENT USE ONLY Application Accepted by — Date a �d Area Pit or Grout inspection by Date Final Insp ction by Hate Additional Comments: r�. GLS r � /� C1Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK RECEIVED BY DATE PERMIT'NO. I INFOjAM�O;UNT DUE AMOUNT REMITTED C \t�fy 229 +.EH 13-24(REV,1/rs 51 ��I 0 ',31:H 14-28