87-2464 - Laserfiche WebLink

Home Browse Search

rye; T - APPLICATION FOR PERMIT T7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES TYEAR FROM DATE ISSUED r (Complete in Triplicate) ` r ' 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 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. f r Job Address Citys of Si a PM { Owner's Name Address Phone oittractor ` Address 1 �� License No. Phone` TYPE OF WELL/PUMP: f NEW WEL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER"LINES " _ ---D1S OSP AL FLD. PROP. LINE FOUNDATION RICULTURE WELt-�— OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public fl Other ` fl Delta D th of Grout Seal Type of Grout I I Irrigation pprox. Depth I I Eastern Surfa Seal Installed by Repair Work Done L] Type of Pump H.P. State Work Done rr Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is -available within 200 feet.) f Installation will serve: Residence_'� :Commercial�"Other e- - r 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. Ll. . Method of Disposal Distance to nearest: Weil 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 t 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-ai 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m It call for all required inspections. Complle drawing on reverse side. _ Ld2 Signed X Title: .�y�i� Date: y FOR EPARTMENT USE ONLY II - Application Accepted by t Date - (Q �OL11�'-70 l 1 Area 0 c Pit or Grout Inspection by Date Final Inspection by 4 1 �!�I�. G J Date /1 S~ v- Additional Comments: f d vi[ r tT C/i L,u-ra La O G e1' zit. r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEECK AMOUNT DUE AMOUNT REMITTED ,1 RECEIVED BY DATE PERMIT NO. k INFO ((� rr,, /l ny� + EH 13241REV.i/nsr -�� V �� - EH 14-26 - 111