87-1751 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ZA SAN JOAQUIN LOCAL HEALTH DISTRICT {may 0 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. Job Address r/e, City Lot SizeX14,7j PM )6'A Owner's Name Address Phone Contractor Address z:2 _.s. ense No. ;3��Phone TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. P. LINE FOUNDATION AgATCUbTUIlE WELL ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR STR SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Excavatr Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Ot ❑ Delta Depth of Grout Seal pe of Grout ❑ Irrigation !L—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destr n ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITI N ❑ DESTRUCTION ❑�p(No septic system permitted if public sewer is X le ithin 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: 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 that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fol ing' "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 li. rnia.11 The applican st call for all requi inspections. Complete drawing on reverse side. [ Signed Title: Date: qt'1—e) 7 • F DEPARTMENT USE ONLY C� Application Accepted by �`s�n ll� < „� - Date v . Area "� Pit or Grout Inspection by p/. Date Final Inspection b Date !9`3� / Additional Comments: 10`9 o ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑Manteca 823-7104 ❑ Tracy 835-638.5 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 14-24(REV.1/0 e) EH 1428 t <