88-415 - Laserfiche WebLink

Home Browse Search

s. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTR(6 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 V �' PERMIT EXPIRES TYEAR FROM DATE ISSUED 1 (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. tb..ddress 2 ' �! (Ci'ty ��- Lat SizePM r's Name �✓✓ Address 3V Jz _ Phone Contracto dress_&-160e License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTH DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P OP. LINE FOU DATION AGRICULTURE WELL OTHER WELL ITS/SUMPS INTENDED USE T ELL — PROB EA CONSTRUCTION SPECIFICATIONS h , L1 Industrial EI Open Bottom a tete Dia. of Wel! Excavation ia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ TE T pecifications ❑ Public l=] Other Cl Delta Depth of Grout Seal ype of Grout _- t I Irrigation --Approx. Depth l I Eastern a1 installed by , Repair Work Done ❑ Type of Pump H.P. S ate Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Fil er Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.l REPAI /ADDITION I I DESTRUCTIO (No septic system p d iF public sewer is �' ailable within 2 Installation will"serve: Residence_ Commercial— ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: v Water table epth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compa nts PKG. TREATMENT PLT. ❑ Method of s sial Distance to nearest: a Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation PropertyLine SEEPAGE PITS I I Depth Size _ Number SUMPS Ll 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 accordance with San-Joaquin c my 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 whici i 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 h ring 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." The applicant njust call for all required inspections. Co late drawing on reverse side. Sig�ad X ,�� Title: KDate: ��/ , OR DEPARTMENT USE ONLY Application Accepted by Q-nzzDate Area i Pit or Grout Inspection by Date Final Inspection,qby&- - Date i Additional Comments: �C 41 ❑ Stk °466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 n Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box)2009,- St ., CA 95201 LF '✓ r�4.�� d-a"'✓ l�r� �� FEE AMOUNT DUEMOUN REMITTED CK RECEIVED BY DATE PERMIT'NO. , INFO H EH 1 3-24 r"EHt4-ZgIREV.t/n51 Ae,��.z�`� ��