89-2746 - Laserfiche WebLink

Home Browse Search

.asp APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 -3 7 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. '3 f r r u.. Job Address v V �� Ci C�l �.Lot Size PM `� � r.r I Owner's Name Address ■ Q Phone �� r , Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F 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 Specifications r , F) Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout—.-- I rout —I I litigation _Approx. Depth i I 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 (Below 50'1 — Sn TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION. (No septic system permitted if public sewer is ` J t// available within 200 feet.) k Installation will4serve: Residence_ Commercial Other Number of living units: —I— Number of bedrooms Character of soil to a d7I.Type/Mfg of 3 feet: Water table depth SEPTIC TANK Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ .Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I I Depth Size — Number t SUMPS ❑ Distance to nearest: Well Foundation Property tine DISPOSAL PONDS ❑ 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 regulation of the San Joaquin Local Health District. Home owner or f en ed 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 pe on i such manne s to ecome subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the f lowi g: "I certify at in performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws CaH rnia." The app c us cal or II re it d inspections. Complete drawing on reverse Signed Title: Date: /��v/ FOR DEP RTMENT USE ONLY Application Accepted by v Date Area { Pit or Grout Inspection by Data Final Inspection by Date Z [� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M85 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO AMOUNT rDUUE' AMOUNT REMITTED C RECEIVED BY DATE PERMIT N[0O., i.EH13-24IREV.1/1151 3��-�/ 3s�o }f EH 14-28