84-1570 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ION AVE., STOCKTON, CA Telephone 12091 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E (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 k 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. Job Address �U City Lot Size PM w T ��al f✓r 5�- I Owner's Name L I ��►�r v�e� Address _ '�L r�✓�► — Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELLfREPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK l SCJ SEWER LINES DISPOSAL FLO. U PROP. LINE FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USES TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z ❑ Industrial I - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications s ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by e; 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 I available 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 I ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f ,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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line kt DISPOSAL PONDS 71 - 4 E 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. �, "(�,L. ,£r , t-, ry , Home owner or.licensed agent's signature certifies the following: "I certify that in the performance of the work for which thi§.permit is issued, I 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 empl'o'y personas subject to workman's compensa- tion laws of California." Theapplican r ust Cali for all required inspections. Complete drawing on reverse side. Signed Title: 4V- ,e 'Date: l FOR DEPARTMENT USE ONLY Application Accepted by Date LAre Date Pit or Grout Inspection by ate Final Inspection by `� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36221 ❑ Manteca 923-7104 ❑ 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 CASH RECEIVED BY DATE PERMIT"NO. INFO +EH 1344(REV.10/831 F,EH 14-26