88-3213 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT '02 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ]PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) d lis Application is hereby made to the San Joaqupermit to construct and/or install the work herein described. This application in Local Health District for a per made in compliance with San Joaquin Couhty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ruleser Regulations f the San Joaquin Local Health District. • 4,5 F � /• l�F QI�J City O� tSt Size 1 x �3 1 PM Job Address �� 7M5 �[/ {/ Z � E ` Address 1�X �7� P"UTI�} Phone Z 1 Owner's Name �e Jf . 1 y L o Contractor �O �iU�fOM HD ttlres445 s fO C T 1A4W I�T�LEense Na. ! 'Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation ; Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public {] Other `' ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _-ApproxG'Depth la Eastern Surface Seal Installed 5y - w Repair Work Done ❑ Type of Pump H P, State Work Done r "U SealingMaterial (to 50`1 " ` Well Destruction ❑ Well Diameter - �r P � t , Depth r °Filler Material (Below 501N° TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION [ I DESTRUCTION I l JNo septic system permitted if public sewer is 1 - r available within 200 feet./ F ! _ Installation will serve. Residence Commercial Other Number of living units: _)_ Number of bedrooms 3 �w Character of_soil to a depth of 3 feet: Water table depth L (_'QNG��fG No. Compartments SEPTIC TANK I- Type/Mfg j PKG. TREATMENT PLT. © , f j Method of Disposal Distance:to nearest: Well --12-4V Foundation Property Line / LEACHING LINE 19- No. & Length of lines �T- T ta! ler gth/size FILTER BED ❑ Distance to nearest: Well ��S Foundation Property Line SEEPAGE PITS Depth 1 Size �� Number r Jp i SUMPS 0Distance to nearest: Well 1 Z 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, 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 Cal' nia." t The applicant II quire i ctions. Complete drawing on reverse side. r-�/ i Signed X Title: V l b of L� Date: FOR DEPARTMENT USE ONLY r` Application Accepted by Date Areay 4 Pit or Grout Inspection by Date Final Inspection by Date �- s Additional Comments: , e ❑ 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.Q. Box 2009, Stk., CA 95201 1 f` FEE AMOUNT DUE AMOUNT REMITTED G SH RECEIVED BY DATE PERMIT-NO. ` INFO f I t.EH 13-241REV.1/H51 95 EH%26