87-551 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j , z; (Complete in Triplicate) _,,,,w. : - 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. Job Address City Lot Size PM Owner's Name Address k CAeA 47 Phone 4 2N-88 Contfactor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Ir DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS c. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing iSpecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Cl Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material Belo ') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION KDESTRUCTION ❑ (No septic system permitted if public sewer is —available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms j 1 Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ T /Mf {o s Ca ac ' Type/Mfg p rty" No. Compartments PKG. TREATMENT PLT. 0 `� '. Method of Disposal Distance to nearest: Well Foundation Property Liney r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �'r tti W SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 i 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. -. i Home owner or licensed agent's signature certifies the following; "1 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 must call for all required inspections. Complete drawing on reverse side. Signed X-_ �� —~� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 116—k Z Area Pit or Grout Inspection by Date Final Inspection by Date 3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 0antaca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO. e, r EH 13-24 EH 13-26(REV.1/B 51 ie, 5�� - �1 tO �- O/ J S r tJ �� Q