88-1953 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JdAQUIN LOCAL HEALTH DISTRICT 1601 E! HAZEL T ON AVE., STOCKTON, CA MTelephone (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. Cit Lot Size_ ��• jahcpM` Job Address �� Y �– Owner's Name • "Address � Phone mlqf-�rtA).p cmp !� FU"'/ cJ 1 l�'L"t� _�� K� � Phone Contractor Address_ License No. TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION LJ a PUMP INSTALLATIONr)i� SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANKQ0 .SE � }�� WER LINES � qq�,,� DISPOSAL FLD.Ioo t PROP. LINEa� I FOUNDATION '- Il AGRICULTURE WELL ►`�06 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �5 ❑ Industiial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing Domestic/Private Travel Pack © Tracy Type of Casing IeP.L __ Specifications f-1 Public Ll Other Y ❑ Delta Depth of Grout Seal ��I-J Type of Grout ' /T I I Irrigation —,Approx. Depth 1-4 Eastern Surface Seal Installed by Repair Work Done LlType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ �] TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 f3EPAiWADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) f^ Installation e: Residence— Commercial Other Number of living units: Number of bedroomslM Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well `. Foundatio Property.Line i LEACHING LINE ❑ No. & Length of lines Total length/sr FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line- SEEPAGE PITS I 1 Depth Size f Number SUMPS L] Distance to nearest: %.9well Foundation Property Line DISPOSAL PONDS ❑ l- p I hereby certify that I have prepared this application and Cthat the work will be 4e in accordance,with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D� � trict. " I Home owner or licensed agent's signature certifies the fallowing: "I certify that in thg rformance'of the work for which this permit is issued, I shall nott^ employ any person in such manner as to become subject to workman's compensation I&wspf California.'• Contractors hiring or sub-contracting signature v �1 certifies the following: "I certify that in the performance of the work for which thisparmit is issued;;1."shall employ persons subject to workman's compensa- tion laws of California." II - -------�• _,_, The applica st calf for all required ins c'ons. Cornlplate drawing on verse side. Signed XTitle: _"} �� –I Date: t F R DEPARTMENT USE ONLY Applicati cepted by Date F CJ r Are I ; ,Z j Pito Grout I pection by Dote Final Inspection by Dat 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 AMOUNT DUE AMOUNT�hEMITTE6RECEIVED BY — DATE PERMIT NO.x INFO �T /O/ CASH +.EH 13-24(REV.t/n5) S�' ` a�, EH 14-26 f