88-1902 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address Lot Size �� /7 PM 9 - I 1 '3 Owner's Name a6 (ZA_(t ZWAtddress r Phone Contractor 'PA�L $ Sa ti+`! Address-T y� %1143T T►91t&a4r^ce� No. 590 95 Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of,Casing Specifications f7 Public F1 Other ❑ 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 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDIS TIOI�LW DESTRUCTION l I (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve:' Residence# Commercial_ Other Number of living units: Number of bedrooms S� � Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments a TREATMENT PLT. C] s ��p � � � )q1&t`or.. Q Save /i Method of Disposal Distance to nearest: We11 (� Foundation Property Line 4.teiv+4T+Dl� _ s I V Y ext Oro Ti�ti LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth I Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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*=�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 notes employ any person in such manner as tri 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applican st call foraequir inspections. Complete drawing on reverse side. C� Signed X (X�yl` Title: Date: FOR !7RTMENT USE ONLY �7 Application Accepted by Date Area pe y P y T �V Pit or Grout Inspection b Date Final Inspection b Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT 1DUE�. AMOUNT REMITTED _ `lICA�(SH RECEIVED BY DATE PER�jMIT'NO. + EH 13-24[REV.i i x s1 �� V V �V- O !V EH 14-�