87-3728 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQVIN 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. t ;. EJob Address - Cit Lot Si2dr- o�� PM Address '�, _...� /1 � Phone. I ner's Name tractoy—ELr_ Address —License No. Phone G t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAI ❑ OTHER C] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A ULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. o ell Excavation Dia- of Well Casing Aw ❑ DomesticIPrivate ❑ Gravel Pack ❑ Tracy Type of C.S. Specifications FI Public n Other ❑ D Depth of Grout Se Type of Grout I I 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 5011 A TYPE OF SEPTIC WORK: NEW INSTALLATION !1 REPAIR/ADDITION l I DESTRUCTION INo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial,_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity J No. Compartments PKG, TREATMENT PLT. ❑ `" Method of Disposal Distance-to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines -'Tota!-lengthtsize }' FILTER BED ❑ Distance to nearest: Well Fotlr dation "' -y `Property,Line - e SEEPAGE PITS `'► II I Depth Size Number SUMPS �tonear�est: �Well Foundation Property Line DISPOSAL PONDS ❑ ! I hereby certify that I have prepared this application and that will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health DistHct., Home owner or licensed agent's signature certifies the following: "I certify that in the ce 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 taws of Cali o ntractor 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 ubject to workman's compensa- tion laws of California." The applicant must c or II required inspections. Complete drawing on reverse side: Signed X Title: Date: R-DEPARTMENT USE ONLY R Application Accepted by Date 7 Area . ' 4 PkNii� Pit or Grout Inspection by J /�} Se:r: EFin�alection by Date Additional Comments: � ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 CA H RECEIVED By DATE PERMIT*NO. INFO t Q �} + EH 1&24 fREV.I/n sl 3 �r `\ �v�„/ f o � (S ?n �' L EH 11-28