87-505 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAO.UINLOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE cviow (Complete in Triplicate) work rein ribed.This cartion is Applications hake with de Sano the San Joaquin Local Health Joaqu n County ordinance No.District549 far sewage or No. 1862 forconstruct we111and/or pump and the Rules and Regulations of the SanrJoaquin made in co p 7 x; Local Health District. I ':. •;v ;r• F E +' PM City Lot Size } Job Address h Address a � Phone ftJC„�y� nwf/�� Owner's NameBil Contractor �' S Address -3 cense No. p�p—Phone F TYPE OF WELLIPUMP: NIIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i SYSTEM REPAIR 171 OTHER ❑ PUMP INSTALLATION ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ��- DISPOSAL FLD. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION " t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ( ❑ industrial `❑ Open Bottom Ll Manteca Dia. of Well Excavation , T ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications Type of Grout 1 ❑ Other EJ Delta Depth of Grout Seal 1:1 public '" l �4pprox. Depth ❑ Eastern Surface Seal Installed by E3 Irrigation State Work Done Repair Work Done ElType of Pump H.P. Sealing Material {top 50') - Well Destruction ❑ Well Diameter \ Depth Filler Material {Below 50');- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION a�ailablelwithm 200 feeted it public sewer is Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms - I Water table depth x Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal _ PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: Well Foundation Total length/size LEACHING LINE ;f 'r❑ No. & Length of lines I Property Line FILTER BED '❑ Distance to nearest: Well Foundation p rtY Size Number SEEPAGE PITS ❑ Depth property Line SUMPS ❑ Distance to nearest: Well - Foundation h DISPOSAL PONDS ❑ f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state caws, and } rules and regulations of the San Joaquin Local Health District. 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 shat not Home Home any person in such manner n to become subject to workman's compensation laws of California."'Contractors hiring or sub-contracting signature of the work for which this permit is issued, I shall employ persons subject to workman's compensa- certifies the following: certify that in the performance tion laws of California." - The applicant st call for all requir i pact ns. Complete drawing on rrse side. Title: Date: Signed FO EPARTMENT USE ONLY Date Area App ation Accepted by ^ Dat Pit or Grout inspection by Date Final Inspection by e a Additional Comments: ❑ Stk 466-&781 L] Lodi 369-3621 ❑ Manteca ffi3 7104 ❑ Tracy 835 6385 k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMITNO. FEE AMOUNT DUE AMOUNT REMITTED "CASH INFO + EM M24(REV.1/851 EH 14-25 -- - -