88-1314 - Laserfiche WebLink

Home Browse Search

ti LAPPLICAT10N FOR PERMIT 1 I± SAN JOAQUIN LOCAL HEALTH _Dl TR1CT 01 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 �_PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 'I (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 i 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 Lot Size PM x, Owner's Name Address Phorfe'�G7 —aasF Contractor Addreu2-5, �iG Licenses Ph e '� 0 4 TYPE OF WELL/PUMP: NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Y: DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PA FOUNDATION AGRICULTURE WELL 0 ELI_ PITS/SUMPS INTENDED USE TYPE OF WELL t PROBLEM AREA CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ M Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack Tracy Type of-Casing Specifications ; a t'1 Public F11 Other Ll 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 i H.P. State Work Done _ IL . Well Destr n ❑ Well Diameter Sealing Material (top 50') Depth 1 Filter Material (Below 50'1 H C TYPE OF SEPTIC'WORK: NEW INSTALLATION I1 "REPAIR/ADDITION I I DESTRUCT105K INo septic system permitted if public sewer is vailable within 200 feet.I Installation will serve:" Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil ia.a depth of 3 feet: Water table depth r SEPTIC TANK- ,j" ❑ Type/Mfg Capacity.- No. Compartments f, PKG. TREATMENT PLT ❑ Method of Disposal Y � 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 r - SEEPAGE PITS I I Depth Site Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 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 iri 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 requira�t' plete drawing on rewrse side. •� Signed Title: Date: FOR DEPARTMENT USE ONLY. t Application Accepted by \LM FIA(5-,� — Date .�'Z T Area (--I Pit or Grout Inspection by Date Final Inspection by Date ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 - f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., PA, Box 2009, Stk., CA 95201 I FEE L- INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. - EH 13-24 IREV.i i'5} �/J 7 Lit ��r✓'� � EH 1429 3