87-2530 - Laserfiche WebLink

Home Browse Search

{ APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 qrn Go N Local Health District. Job Address C fr - City Lot Size PM Owner's Name m L PLOTA d e so u�-�� {.�F4�.5 9 Phone 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. E FOUNDATION AGRICULTURE WELL OTHER W PITS/SUMPS gg INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR PECIFICATIONS © Industrial ❑ Open Bottom 0 Manteca ia. of Well Excavation Dia. of Well Casing rte-- 1 ❑ Domestic/Private (71Gravel Pack y Type of Casing Specifications �- I-1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout 1 Irrigation Approx. Depth I I Eastern Surface Seas Installed by - Repair Work ❑ Type of Pump ^� H.P. State Work Done we struction ❑ Weil Diameter Sealing'Material )top 50') Depth Filler Material (Below 50'14 _ 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIRlADOITION I I DESTRUCTION I (No septic system permitted it public sewer is available within 200 feet.] .installation ilk.:serve: Residence_ Comm rci�al —Othe Number of living units: Number of bedrooms Water table depth i Character of soil to a depth of 3 feet: I SEPTIC TANK ' ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number ` SUMPS Ll 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. 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 wotkman's compensation laws of California."Contractor's hiring or sub-contracting signature I 'certifies the fdllowing: "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." t The applicant must call for all required inspections. Complete drawing on reverse side. �{ Signed X ��l�l� Title: -Date: FOR DEPARTMENT USE ONLY I Application Accepted by Date .r3a� Area /93 Pit or Grout Inspection b Date Final Inspection by Data ti Additional Comments: L � LIM ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 K RECEIVED BY DATE f ERMIYNO. INFO vq/�) J i ♦ FH 1324IREV.r/Ksl v� / EH 14.28 / _ r ,