87-952 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ' r j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA (\, 0 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED W " (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/ um and the Rules and Regulations of the San J Local Health District. f+ p p e9 Joaquin Job Address v �AA JCA M1 � •4 y .. .� � �/�}' City Lot Slze `S �1fa V PM Owner's Name Address ( ,\ Phone < `,Contractdr� ' _ res License. icense No. -��• - Phone TYPE.OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ t' DESTRUCTION ❑ i .-,;y PUMP INSTALLATION ❑ SYSTEM REPAIR Eli OTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISP05AL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca'""� 'pia of Well Excavation Dia. of Well Casing j ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑_Public 1 ¢I-,--- ❑ Other i t ❑tDeits Depth of Grout Seal ( Type of Grout ❑ Irrigation .,Approx. Depth—OlEastern Surface Seal Installed by 2 r Repair Work Done ❑ Type of'Pump j H.P. State Work Done ! Well Destruction ❑ Well-_Diameter Sealing Materia'11top 501 1 Depth j Filler Material (Below 50') ! / { U TYPE OF SEPTIC WORK:0NEW INSTALLATION ❑ REPAIR/ADDITI0�1 ❑ ESTRUCTION INo septic system permitted if pu lic sewer is I d/J]P/ ailab within 200 feet.) 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 '2 No. Compartments ' PKG. TREATMENT PLT. 0? # Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines- Total length/size- FILTER ength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPSLi Distance to nearest: Well Foundation PropertyLine DISPOSALIPONDS ❑ t i, 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 Disfric`t , 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 i 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." .1 - The applican must call fo SII require 'nspections. Complete drawing on reverse side. Signed Title: j —- Date: FOR DEPARTMENT USE ONLY ApplicationlAccepted by Date �1 f 1 Area al Pit or Grout Inspection Date _ Final Inspection by _ Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi `369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ,.; A. } FEE AMOUNT AMOUNT REMITTED INFO DUE CK RECEIVED SY CASH DATE PERMIT'NO. + EN13-24{REV.t/s57 �� EH 14-28