87-3841 - Laserfiche WebLink

Home Browse Search

•may., APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT NO�tti I 1601 E. HAZE T ON AVE., STOCKTON, CA alyL I Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR 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. L Job Address ,7 y 6p / U — City (9Glr Lot Size PM i� ,�/ Phoner44- OF-2Owner's Namlf, `�/�' �i dress _ `a t 1 , t Contractor — t Address 4 O License No. Phone TYPE OF WELL/PUMP:.. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES SPO L FLD. PROP- LINE FOUNDATION AGRICULTURE WEL OTHER , ELL PITS/SUMPS INTENDED USE TYPE OFIWELL OBLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ M ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tta Type of Casing Specifications x ❑ Public ❑ Other {_l elta of Grout Seal - Type of Grout I i Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work bone Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBeilow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I } DESTRUCTIO (No septic system permitted if public sewer is Y available within 200 feet.) r 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 k SEPTIC TANK C1Type/Mfg r Capacity No. Compartments I PKG. TREATMENT PLT. ❑ 1 r Method of Disposal Distance to nearest: Well r Foundation Property Line LEACHING LINE ❑ No. &,Length of lines F Total length/size Ir FILTER BED ❑ Distance to nearest: Well Foundation Property Line ;I - SEEPAGE PITS I Depth,I Size N-umber- 1 { SUMPS ❑ Distance to nearest: Well Foundation Property Line � 1 ? DISPOSAL PONDS ❑ ,, r 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."Contractor's hiring or sub-contracting signature certifies the following: "I certify that tri 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 st call for all requir hs ctions. Complete drawing on reverse side..,/ 7�� Date: w Signed -- Title: EPARTMENT USE,ONLY. .. w Application Accepted by Date D Area { Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: I I ❑ Stk' 466-6781 ❑ Lodi 369,.3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE i INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. a EH 13-24 iREV.I/H 51LjA EH 14-28 k.