87-917 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 'G SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 t _.` 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. Job Address City Lot Size PM Owner's Name 164 C�2 116 Phone Contractor Address F� License N ( Phone , Q TYPE OF WELL/PUMP: ' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI DISPOSAL FLD. PROP. LINE FOUND ON 3QPICU TURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack El Tracy Type Casing Specifications `1 L1 Public E-1Other ---B-Bella—' rout ea Type of Grout �f+ ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Worl Done Well Destruction ❑ Well Diameter (Sealing Material (top 501 Depth ler aterial (Below 501 TYPE OF SEPTIC WORK: NEW INSTAL TION ❑ REPAIR._ DDITIQN ❑ D TRUCTION Tavaibple c system permitted if public sewer is " V within 200 feet.) Installation will serve: ResidenceCommercial_ 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. El Method of Disposal Distance to r earest: Well Foundation Property Line �( LEACHING LINE ❑ No. & Lengtf of lines Total length/size FILTER BED ❑ Distance to rest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 thpt in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become N ct to rkman' co ensati 2's- The f Cal' rnia."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perfor a work fo i is itsu I shall employ persons subject to workman's compensa- tion laws of California." applicant must call fora'required inspe ti ns. Complete drawing on ev4rse side.-m Signed 1r Title: �l� Date:, 5—,2y— f'? F-QR DEPARTMENT USE ONLY Application Accepted by Cw �. Date a� Area 15 Pit or Grout Inspection by Date Final Inspection by Date 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.t i a s) +�-.,G,� G �T O c) EH 1426 ✓J �j �J(� `�J �" 1 i