87-1231 - Laserfiche WebLink

Home Browse Search

i 4 17 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA - Telephone (209) 466-6781` PERMIT EXPIRES 1 YEAR FROM 'DATE--ISSUEd�. (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 Ryles and Regulations of the San Joaquin Local Health District. .,. t Job Address �, G fr<,60 4�f ' City'' Lot Size PM A Owner's Name t'L Address�1s Phone r � 7 Contractor 90? dress i License No 3 ` Phon -7 r { _ 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i-q/nomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications ❑ Public ❑ Other - ❑ Delta Depth of Grout Seal- Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. L r7� _ State Work Done !, Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [;]-„,DESTRUCTION ❑ ,(No septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence_ Commercial. Other f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: �X'Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r - ----,--- Method of Disposal Distance to nearest: Well Z\! Foundation Property Line LEACHING LINE ❑ No. & Length of lines w Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property 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. f 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 all f all require inspections. Complete drawing on reverse side. 4 Signed'X Title: Pate: FOR DEPARTMENT USE ONLY Application Accepted by 4n I W, Date r 3 f.7"' Area 10 Pit or Grout Inspection by Date Final inspection by - Date "�7 r 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.!, CA 9520.1 - FEE AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY: DATE PERMIT'NO. INFO CASH f -.+EH 13-241REV.r/a5) J1 ' f _..r �I•. :.` EH 1426 V