88-2793 - Laserfiche WebLink

Home Browse Search

M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-67$1 PERMIT EXPIRES TYEAR 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. � Job Address 4S +`r! 00LA Ciity�OA/ Lot Size 50 x 120 PM Owner's Name ��iZ ��LAddress �T 72- CAW C�L1Q Phone -7�� /O 2-0 Conractor QTM { t10rTM AI S Address3X5 POS L Af- License No Phone t !Z3-5-0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA ION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES ISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROS MAR CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ M x { Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing > Specifications i'1 Public F1 Other } Cl Delta Depth of Grout Seal Type of Grout F 1 I Irrigation :-App Depth i I Eastern ace Seat Installed by _ Repair Work Done ❑ Type of Pu H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material It 50') Depth Filler Material (Bel TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION D RUCTION 1Na septic system permitted if public sewer is (� ��vdllable within 200 feet.) U t _ Installation will serve: Residence{ Commercial_ Other Number of living units: Number'of bedrooms Character of soil to a depth of 3 feed Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ! Method of Disposal ' Distance'to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distancelto nearest: Well Foundation Property Line SEEPAGE PITS 11 ' Depth Size Number ' SUMPS 0 Distanceto nearest: Weil 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 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, 1 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." `f The lican must c I for all qui ed inspections. Complete drawing o averse side. Signed X _ Title: Data: FOR DEPAR ENT USE ONLY �D Application Accep d byd06 Date All((}yy([XJArea L Pit or Grout Inspection by t Data Final Inspection by tr Date Additional Comments: tf-.0.Y'n't-N- ig t� ` a 3� dd . (y CO L4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 1 ❑ Tracy 839-6385 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 RECEIVED BY DATE PERMIT'NO. INFO ��y� C + EH 53-24IREV.r/n5) 2- L! �S' �� ,�� g Z� 3 EH 14-2e y - d