88-1590 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQIUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED F. (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. PM .lob Address �7' G Lot Size B Phone Owner's Name F- fy c'P Address Contractor �� Addfess vQ l"v 9de". License No. �y Phone OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION ❑ j 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 Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public i-I Other 71 Delta Depth of Grout Seal Type of Grout —. p I I Irrigation --Approx. I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump W.P. - State Work Done Well Destruction ❑ Well Diameter `Sealing Material Itop 501 DepthTFiller Material (Below 501 ` f TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION Li DESTRUCTION l I (No septic system permitted it public sewer is a available within 200 feet.) ZS Installation will serve: Residence '► Commercial Other Number of living units, f Number of bedrooms ro Character of soil to a depth of 3 feet: �- Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT'(] Method of Disposal Distance to nearest: Well Foundation' Property Line /p Total length/size LEACHING LINE �'❑ No. & Length of lines � '� g sProperty .T FILTER BED x. ❑ Distance to nearest: Well 00 b Foundation 10 Line -1 I I f SEEPAGE PITS I I' Depth 13" Size, t' .Number. 3 EA '� p� SUMPS Ill= Distance to nearest: Well 000 Foundation -� Property Line DISPOSAL PONDS ❑. I t 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 f 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'f&which This permit is issued, I shall not employ any person in such manner as to6come subject to workman's compensation laws of'California.."Contract6r's hiring or sub-contracting signature certifies the following: "I certify'tha't in th'e performance'of the work for which this permit is issued, i shall employ persons subject to workman's compensa;y tion laws of California." ' I The applicantmus aA for all required inspections) Complete drawing on reverse side. f " Signed X <FOdx'Title: Date: FOR DEPARTMENT USEONLY _ y_ 3 Application Accepted bygn . M Date Area ^� Pit or Grout Inspection by Date ' _ —Final Inspection y �' Date' 41 Additional Comments: ^�' ❑ Stk 466-6781 ` -A ❑ Lodi X369-3621 ❑ Manteca '823-7104 ❑ Tracy '835-638& ,;,,t Applicant - ReturA all copies to: Enyirenmental Health Permit/Services 1601 E. Hazelton Ave., P.O: Box 2009, Stk., CA 95201 t/21 FEE I INFO AMOUNT DUE` AMOUNT REMITTED RECEIVED BY DATE PERMIYNO. , ♦ EH 13-26(REV.i/y 51 *7dS !1-�� 19:�O EH t4-2e