87-1807 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT = SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)'466-6781 Mf ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED zti ,, ..:•� 1 1,(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. 4��yy S ' PM Job Address _ ` �S!` �' ` ',i City Lot"Size Owners Name '1- r "' Address �� y \ 1,\ �(� .y Phone 1 n � N Contractor + Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ --r-1-PUMP-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia. of Well Casin Ll Industrial ❑ Open Bottom ❑ ieca Dia. of Well Excavation ' g 0 ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications V`\ ❑ Public ❑ Other F ❑ Delta Depth of Grout Seal Type of Grout ; ❑ Irrigation �4 x.#Depth ❑ Eastern Surface Seal installed by Repair Work Done ❑ T of Pump H.P. State Work Done Well Destruction ❑ ell Diameter Sealing'Material (top 50'1 `} Depth # Filler Material.(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ' (No septic system permitted if public sewer is -available within 200 feet.) ! Installation will serve: Residence— Commercial Other i !Number of living units: Number of bedrooms � Character of soil to a depth of 3 feeta F Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well" Foundation Property Lint- Total ine Total length/size l h/size LEACHING LINE" El ..No. &'Length ofli es-.- „ i FILTER BED ❑ Distarice to nearest: Well;- Foundation Property Line SEEPAGE PITS' ❑ Depth Size°- - Number SUMPS ❑ Distance,to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .1 I hereby certify that I have prepared th s 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 e inspections. Complete drawing on reverse side. Signed X /� LZI r } Title: a�'�- Date: ' FOR DEPARTMENT USE ONLY Application Accepted by Date Area C I� y 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 ;AyM0UNTDUE; AMOUNT REMITTED CK RECEIVED BY GATE PERMIT"NO. ( INFO -D:, "+ EH 13-24 iREY: /e 61 EH 14-28 _ n.