87-4037 - Laserfiche WebLink

Home Browse Search

' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Job Address � ` �/��i(/t __ !.4!y - City Lot Size PM f Owner's Nlam-Q4� Address /�'Jy-�� Phone Contractor 47 Addres4 � License Phon� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,❑ _,-______SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL ! /SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC IFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel.Pack ❑ Trac Type of Casing Specifications 'J\ fl Public Cl Other elta ° Depth of Grout Sea! Type of Grout _. I I Irrigation -Appro Ph I 1 Eastern Surface Seal Installed by Repair Work Done C7 T ump H.P. State Work Done' Well Destruction Well Diameter Sealing Material (top 50') f s Depth �w5._Filler Material (Below 50'i — - - -- TYPE OFwSEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION') l DESTRUCTION No septic system permitted if public sewer is r "'available within 200 feet-! Installation will serve: Residences'_ Commercial_ Other Number of living units: Number of bedrooms ; Character of soil is a depth of 3 feet: _ _ f Water table depth SEPTIC TANK El Type/Mfg T Capacity � ¢ #No. Compartments \\� V+ j PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundations Property Line [t�� LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well r Foundation Property Line SEEPAGE PITS I'1 Depth Size Number SUMPS Ll Distance to nearest: Well f=oundation Property Line DISPOSAL PONDS Cl 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 taws of California."Contractor's hiring or sub-contracting signature certifies the following: "I cortify.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." r ' The applican ust call for all required spections. Complete drawing on rev se side. I Signed X Title: ._ Date: FOR DEPARTMENT USE ONLY Application Accepted by ____-_— �_ _.. Date s g Area t/ Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-362 ❑ Ma en�t ca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' i FEE INFO AMMO)UNT DUE AMOUNT REMITTED /KK RECEIVED BY DATE �} PERMIVN.O./ + EH 13-24 iREV.t/n 5) EH 14-28 ••/ C/ ` VCS � !! G