90-211 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 No , L, a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED „ (\ (Complete in Triplicate) (iIt 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 (9;2 3 , City Lot Size! 4 PM Owner's Name�w�. L �7�Ad � dress /%6 � Phoneq�� Contractor �//! b�j Address icense No.�L Phone_ �✓ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA MENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYST REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWE INES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA O RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of II Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Cast Specifications FI Public ❑ Other ❑ Delta Depth of Grout I Type of Grout __ I I Itrigation __.Approx. Depth I I Easter Surface Seal Installed _ Repair Work Done ❑ Type of Pump H.P. Sta Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l I DESTRUCTION (No 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in th performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Califo nia' The applican mus I for a ; s lions. Complete drawing o ve se side. Signed X Title: Dat RTMENT USE ONLY � IApplication Accepted by Date_ l-- Area 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 G} PERMIT'NO. + EH13-24(REV.1/n 5) EH 14-26 CG.//