88-2693 - Laserfiche WebLink

Home Browse Search

2 APPLICATION FOR PERMIT EST SAN JOAQUIN LOCAL HEALTH DISTRICT pG 1v9 �j� 1601 E. HAZEL T ON AVE., STOCKTON, CA * �� , ✓ Telephone (209) 466-6781 SEQ �, �9 4�N PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �N�R*�+AtPI !Complete in Triplicate? N aLw _ p _��Nv1RQNM�S�R�IC�S Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h 'n descitaRis application is made in compliance with San Joaquin-County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and egulations of the San Joaquin Local Health District. a©B� Job Address _ /L } / -_/ City � Lot Size K keil PM Owner's Name /I�Q✓�'V ��(.liYL > Address -0 33 6 - d1 [ 656&"' Phone Contractor el `J Address %55-k571 XlOdLhicense No. nC �l Phone 5-"'11 A5 r TYPE OF WELL/PUMP: NEW WELL 9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK r1CtYI SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /a p, Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing p1/C1 Specifications M Public 71 Other F Delta Depth of Grout Seal rS'© �'' 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 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.) REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is \' available within'200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of sol to a depth of 3 feet: 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 ❑ Distance to nearest: Well Foundation Property Line (� SEEPAGE PITS ( I Depth Size _ Number SUMPS C1 Distance to nearest: Well_ Foundation Property line y' \Q `J DISPOSAL PONDS ❑ V 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 1 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 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 m st call for all required inspections. Complete drawing on reverse de. 4 Signed I Title: Date:- (?—,z�—!1 �F.QPATMENT USE ONLYC�Application Accepted by Date !0— ..___ Area I Pit or Grout Inspection by Date ,ffi Final Inspection by Date 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 95291 FEE INFO AMOUNT DUI: AMOUNT REMITTED CASH / RECE ED BY DATE �-( PERMIT'NO. +.EH t3-241REy.I H5f ��. 70, CO �1 ,(� EH 10-26 3