87-4326 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I ` (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. Job Address -_� [ UIQ S to� City S` Lot Size PM Owner's Name � �'"�`\�`� r"� lress` Phone Contractor � L-�F k�L Address � D (2-L14 License No.` 0 Phone 9C T TYPE OF WELL/PUMP.; _ _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTICTANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom ,❑JJlanteca Dia..of Well Excavation Dia. of Well Casing 11 Domestic/Private --�❑ Cst�Gel`fFac�c t- ❑ Tracy Type`of Casing Specifications FI Public ❑ Other l7 'Delta Depth of Grout Seal Type of Grout I t Irrigation —,Approx. Depth—1i I Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump t H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filter Material f Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION-I 7 -REPAIR,LADDITION-a-1 -DESTRUCTION I septic system permitted if public sewer is available within 200 feet.i 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ! e Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines I Total length/size k FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number I SUMPS 0 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 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 mploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certr- he following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's laws o liforni e applicant a I.for Ire s. C plate drawing on reverse si e- Signed Title: Date: 7-S Y E FOR DEPARTMENT USE ONLY ` ¢� � Application Accepted by 1" f 4, Date — Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:i\�!1 ,�LQJti'w� ' ❑ Stk 466-6781 ❑T6di 369 3621 ❑ Manteca 823-7104/ ❑ Tracy -835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2609, Stk, CA 95201 INFO AMOOUUNT DUE AMOUNT REMITTED CASHFEE RECEIVER BY RATE PERMIT NO. + EH 1324(REV.1/n 5) . 5_ 0 / EH 14-18 L 1