87-562 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTION AVE., STOCKTON, CA {A Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATEISSUED (Complete in Triplicate) A 1.pplication 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 ^i . city Size . PM Owner's Name Address Phone Contractor J icense No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION FT PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PLINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP TIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ofcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy �nepthoof Casing Specifications ❑ Public El Other ❑ Delta Grout Seal Type of Grout ❑ Irrigation --Approx. Depth astern ,_Surface Seal"Installed by " I Repair Work Done ❑ Type of Pump H.P. State Work Done 1 Well Destruction ❑ Well D" ter Sealing Material Itop 50'1 ! th Filler Material {Below 50'1 TYPE OF SEPTICS K: NEW INSTALLATION ❑ REPAIR/ADDITION 11DESTRUCTION (No septic system permitted if public sewer is G i available within 200 feet.) 1 Installation will serve: Residence— Commercial— Other v Number of living units: Number of bedrooms ! Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well foundation Property Line _ l LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well FoundationProperty�Line- SEEPAGE PITS ❑ Depth Size Number SUMPS " ❑ Distance to nearest: Well 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. V,T { 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 us If"111jequillIKI i pections. Complete awing eve se side. Signed Title: i Date: FOR DEPARTMENT USE ONLY 9 Application Accepted by Date O 7 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71&... cy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH M24IREV.t/851 EH 14-28