87-2893 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT E 1601 E. HAZEL T ON`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. P Job Address Cit I�tr,$ e PM Owner's amp Phonel0 Contfactor x �- Address f/ r O �C74 License No, TYPE O ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE y I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f�'1��Public ❑ Other 171 Delta Depth of Grout Seal Type of Grout lyl'Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Wr'�Type of PumpH.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'i \` Depth F s '\Filler Material (Below_501 \\\ TYPE OF SEPTIC WORK: NEW INSTALLATION.W REPAY;/Ai)DITiON l I DESTRUCTION f I (No septic system permitted if public sewer is available-within 200 feet.), „ installation will serve: Ffiesidence_ Gomrnercial�_� 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 ' No. Compartments PKG. TREATMENT PLT. ❑ ', Method of Disposal ` Distance to nearest: Well '- Foundation.1`.1 Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well = - '_-1F60ii-da"ti6n Property Line SEEPAGE PITS I I Depth Size Number SUMPS L� Distance to nearest: Well ? Foundation "T' _ Property Line i 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 rules and re gu the San Joaquin Local Health District. Home own or license ent's signature certifies the following: "I certify that in the performance of,the work for which this permit is issued, I shall not employ a person in suc manner as to becomes ct to workman's compensation laws of California'."Contractor's hiring or sub-contracting signature certifies he following: "I c the h rfor a e of the work for which this per is issued, I shall employ persons subject to workman's compensa- tion is s of Califor ia." The ap licant mu or all plate drawing on raver e. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Data -71�cc� T Area �D Pit or Grout Inspection by bate Final Inspection by 4d__W1 Date A4 S Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AM T EMITTED CASH RECEIVED BY DATE PERMIT N0. + EH1 3-24IREV.I/85) c/! �51 0 EH t4-28