87-2875 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAU`HEALTH DISTRICT 1641 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete'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 c City Lot Size PM Owner's Name Address IL f 2 &SLtt Lf tti/1 f Phone Contractor dress, License Nol_0Phone TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA '.CON StRUCT.ION.SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation t f Dia.,of Well Casing r ❑ Domestic/Private ❑ Gravel Pack_ .._ ❑ Tracy - Type of Casing Specifications 1"1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout cr i I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done -.❑ Type of Pump H.P. State Work Done_ W Wel! Destruction ' ❑ Well Diameter Sealing Material (top 50'1 4 , r Depth Filler Material (Below 501 N TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1- REPAIR/ADDfTION i I DESTRUCTION INo septic system permitted if public sewer is -available 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 ' No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ ''Distance'to-nearesf: Well Foundation Property Cine SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 shat! 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 f certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ-p ' ersons subject to workman's compensa- tion,laws of Californi - The applic t ust a far a!1 r it d inspections. Complete drawing on reverse side. r Signed X Title: r Date: ..FOR.DEPARTMENT USE ONLY f Application Accepted by " 1Ln Date - Area r . Pit or Grout Inspection by Date Final Inspection by bate z Additional Comments: aZ 2 71 12 ❑ Stk 466-6781 ❑ Lodi 369-361_ ❑ 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` C///777SH -RECEIVED BY �D/A�TE��`� PERMIT'NO. + EH13-24 iREV. /w 51 - ._ EH 14-16'