87-322 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA (l �� Telephone (209) 466-6781 L� 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. ,gip Job Address ti �ry> City Lot Size! PM Owner's Name q"_ Address � Phone Contractor ddress License No. Phone / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation prox. Depth ❑ Eastern Surface Seal Installed by .- Repair Work Done Type of Pump H.P. State Work Done Well Destr ❑ Well Diameter Sealing Material (top 50') LA Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLAT available within 200 feet.) ❑ REPAIR/ADDITION El El septic system permitted if public sewer is G 7 Installation will serve: Residence_ Commercial_: Other Number of living units: J_ Number of bedrooms ^— ? Character of soil to a depth of 3 feet: Water tabje depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation P pe L�1fl LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Z^75 Foundation Property Line 5 SEEPAGE PITS ❑ Dept ze Number / SUMPS E] 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 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 must call for all requ' i pections. Corn Ito drawing on rev psipside. �— Signed Title: _,Q�^Tt Jk /i Date: R PARTMENT USE ONLY Application Accepted by �,,v� 'cz� Date Area Pit r Grout Inspection by - Date ,g_-a7-0 Final Inspection by a4lj A 1AA Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M 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 CASH CK RECEIVED BY DATE PERMIT"NO. + EH13.24(REV.1/e 5) �� s EH 14-28