86-1256 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE1: .'.TON� 9 AVx. E., STOCKTON, CA , Telephone {209} 466-6781 / PERMIT EXPIRES VYEAR FROM DATE ISSUED ;rte t icomplete 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 4 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. '.f 4 Job Address I " City Lot Size ISdPM Owner's Name Address 73 C r Phone Contractor z Address_ License No. Phone LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J MP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTI SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. II Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack _ ❑ Tracy Type of Casing 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. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 available within 200 feet.) 1. °Installation will serve; Residence Commercial_ Other f Number of living units: - Number of bedrooms (�) Character of soil to a depth of 3 feet: A Water table depth 9 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (� s PKG. TREATMENT PLT. ❑ 'I Method of Disposal Distance to nearest: Well Foundation, Property Line f LEACHING LINE No. & Length of lines V 'Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation . Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 regulations of the San Joaquin Local Health District. 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, 1 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 applic t must call for I r uir inspections. Complete drawing.on reverse side. Signed Title: •o �.".-....-Date: {' FOR DE ARTMEN USE ONLY Application Accepted by Dafn -53A ..L& Pit or Grout Inspection by I Date Final Inspection by DateAf� r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant-.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE - INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO. + EH 13-241REV.1/857 .� Q� 1 � �0�� ' EH 14-28 6179 i' }