87-364 - 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 (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. O .,, ...Yt :r. u..y ., . Job Address00 ty Lot'Size' PM -Owner's Name L S-C.(wo Address �� ` t �� ""` Phone 2- 70 I Contractor Address License No. Phone f TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION I.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 ❑ Domestic/Privaie ;t ❑ Gravel Pack ❑ Tracy Type of Casing Specifications El Public ❑ Other F] Delta - Depth of Grout Seal Type of Grout F F1irrigation's`� �a ---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 50') Depth Filler Material (Below 501 PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted 'rf public sewer ' available within 200 feet.) �1 Installation rve: Residence_ Commercial_ Other lj Number of living units: Number of bedrooms r 1 # v Character of soil to a depth of 3 r table depth -I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i" " Method of Disposal Y Distance to nearest: Well ation Property Line I r t � LEACHING LINE ❑�No. & Length of;lines n l �Iength/size- LineFILTER BED j,.x(iq.. ❑'Distance to st: Well ` Foundation SEEPAGE PITS Depth "Size' �' Number SUMPS ❑ Distance to nearest: Well Foundation Property Line AL 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. 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 sub-contracting signature I 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 require inspections. Complete thawing on reverse side. ' { Signed - - Title:" bate: }& FOR DEPARTM NT USE ONLY Application Accepted by Date a Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Lei } ❑ Stk 466.6781 ❑ Lodi 3694fiU1 qt` ❑"Manieca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental;Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE r INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITi`NO. 2+ EH 3-24IR&.1/esl �= " EH 1 l .,,. ,- .3 ,