29-806 - Laserfiche WebLink

Home Browse Search

insPeevor"s APPLICATION FOR PERMIT Wei) SAN JOAQUIN LOCAL HEALTH DISTRICT IN 1601 E. HAZEL T ON AVE:, STOCKTON, CA 30 P+n Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is her 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. Job Address City � Lot Size PM q mOwner's Name Address eu Phone ittrc � License N0. /33c Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO AL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHERVELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICIATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic I Private Q Gravel Pack j ❑ Tracy Type of Casing Specifications. s: [`l Public [A'Other ' n Delta Depth of Cxlout Seal Type of Grout _ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 1501 f Depth Filler Material iBelow�D'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION l'1 (No septic sy1� 200 ;n-5 permitteif public sewer is available withfeet) (� Installation will serve: Residence Commercial_ Other I Number of living units: Lf)kJ_4?—Number of bedrooms 3 Ste- I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK t� Type/Mfg +� Capacity-_FcNo. CompartmentsIV �[ Method of Disposal PKG, TREATMENT PLT:I] Distance to nearest: . -Well 00 r Foundation _It I Property Line .90 . I LEACHING LINE No. & Length;of lines Total length/size FILTER BED Distance to nearest: Well� W Foundation do , Property Line Fid SEEPAGE PITS I&f Depth Size Number I SUMPS Distance to nearest: Well Foundation 44b Property Line DISPOSAL PONDS ❑ 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 Dj%trict. 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 j employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i 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 applicant ust call for all re ire specti s. Complete drawing on reverse side. ( Signa /►L- Title: Date: fi R DEPARTMENT USE ONLY I y Application Accepted by Date_44 " Area ! 1 Pit or Grout Inspection by Date Final Inspection by Date t - 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 CK 4 IFEENFO OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE 1 PERMI-[ N I.-EH13-241REV.rrn51