87-4240 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT L 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 heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is r made in compliance with San Joaquin CountyOrdinanceNo.549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �� ne_r V/Z <a fy HiQ</ City 4'tXAJ Lot Size PM Owner's Name Address -5o1.'fA!F Phone S= Contractor dEg ?d YD zs-. &I, Address License No.6L CCX7Z, Phone -1971 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D 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 Weil Excavation Dia. of Well Casing r , ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy` ? Type of Casing Specifications I`1 Public ❑ Other 17 Delta Depth of Grout Seal Type of Grout _ 1 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by r - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth �". """"Filler Mateiial (Below'501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is I/ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other - Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth . fY SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments lJ t PKG. TREATMENT PLT. ❑ Method of Disposal J Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance-to,nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth �(� Size Number SUMPS ❑ Distance to nearest"—We11-- Fiiundd-bon"""'"' Property Line DISPOSAL PONDS ❑ E - 1 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. . C 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 Q, employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature P certifies the following: '9 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." I r The applicant must call for all required inspections. Complete drawing on reverse side. Signed X . ) Title: __[' t Date: r R-DEPARTMENT USE ONLYx+ � Application Accepted by ' a ' Date k7 rea Pit or Grout Inspection by _ Date Final Inspection by e r Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant • Return all copies to: Envirorjmantal Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT NO. + EH 13-241 REV.1/H 51 EH 14-26