88-412 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ' SAN JOAQUIM-LOLAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA W, Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED ' . ; `4 (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 sewaga or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 9KJob Address City, t Size PM Owner's Name Add Phone Phone Contractor tltlress (cense N Phone ' TYPE OF WE 1171 L/ U P: NEW ELL ❑ W L REPLAC>MENT DESTRUCT ON 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 D Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing ❑ Domestic/Private d Gravel Pack © Tracy Type of Casing I Specifications I'] Public C! Other L] Delta Depth of Grout Seat Type of Grout I 1 Irrigation —Approx. Depth I i Eastern Surface Seal Installed by t _ Repair Work Done ❑ Type of Pump H.P. _ State Work Done_ S Well Destruction ❑ Well Diameter] Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REAZoth., DITION l 1 DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_,: Commercial 1 ` Number of living units: Number of bedrooms i Character of soil to'a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity rV14,01 No. Compartments PKG. TREATMENT PLT. t] i Method of i Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size IF I FILTER BED ❑i Distance to nearest: Weil,�j Foundation� Property Line SEEPAGE PITS,, I 1 Depth Size _ Number SUMPS ❑•i Distance to nearest: Well &n Foundation An Property Line DISPOSAL PONDS 1-11 hereby certify that I haveprepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and s rules and regulations of the San Joaquin Local Health DiMrict. r 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 subcontracting signature certifies the following:,"I eariify that in the performance of the work for which this permit is issued, I shall emptoy persons subject to workman's compensa- tion laws of California." ' t The applicant regg4jed inspe o s. omplete drapog onre side. Signed X ] it[e: �" _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date _ Area Pit or Grout Inspection by Date Final Inspection bye► �. Date Additioriai 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 f y INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. ..EH 13-24(REV.1185) EH 14.26 i -