87-1891 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT U SAN JOAQUIN LOCAL HEALTH DISTRICT Ul �a�L 1601 E. HAZELTON AVE., STOCKTON, CA �� f Telephone (209) 466-6781 ✓ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iComplete in Triplicate) kApplication 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 i 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. i Job Address -� »__ _ City Lot Size PM Owner's Name Address Phone i I Contractor �] � Address �` S 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. PROP. LINE FOUNDATION , AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ROBLEM AREA CONS ION SPECIFICATIONS ❑ Industrial El Open Bottom anteca 1a. of Well Excavation Pia. of Well Casing ❑ Domestic/Private - ❑ Gravel Pack ❑ c Type of Casing Specifications M Public F1 Other elt Depth of Grout Seal Type of Grout I i Irrigation _..Appro t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.: State Work Done Well Destruction ❑ Well Diameter Sealin Material (top 50') ^ n Depth Filler Mat 'al IBelow 501' U� TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION { I DESTRUCTIONY (No septic system permitted if public sewer is available within 200 feet.t 11 - Installation will serve: Residence� Commercial— Other Number of living units: Number of bedrooms a Character of soil to a depth of 3 feet: Water table depth j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'l Depth Size Number i 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 1 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 workman's compensation law`s of California." Contractors 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 applican u t call for required tions. Complete drawing on re a side. i Signed X Title: y Date: I FOR DEPARTMENT USE ONLY 3 E Application Accepted by Date r--/` � Area /// Pit or Grout Inspection b Date Final Inspection by Date 1 r Additional Comments: to U e - 1,y -�Y (�, Z— 2 I, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6985 Applicant • Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk;, CA.95201 INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �j + EH 13-241REV..iin5l - EH 14-26