87-1620 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ' J ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 CA, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � t (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 d City Lot Size PM �� Owner's Name Address Phare 121 � ( 2.<- Address 9 7 �J License No. Contractor &1c� Po ~ Phoneme TYPE OF WELUPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ I OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial f ❑ Open Bottom ❑ eca Dia. of Well Excavation r Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by f Repair Work Done Type of Pump H.P. State Work Done Well Destructi ❑ Weli Diameter Sealing Material {top 50.1 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONa septic system permitted if public sewer is I 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well ` Foundation Property'LinV � DISPOSAL PONDS 1:11.s, 1 " —1. 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. I I I i'" Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the w work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's comperisation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work forTwhich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant y stc ll for II se rI ed ins "_ctions. Complete drawing'on reverse si , Signed X � � I - --_-Title .� f to Date: TU5EOLY AreaApplication Accepted by Date � ' �, r Pit or Grout Inspection by Date F raj Inspection by Date Additional Comments: ❑ Stk—466-6781—❑ Lodi"'369-3621"'"""'❑ Manteca#823-7104 —❑ Tracy 8355-6385 Applicant_-Return all copies to:.Environmental Health.Pe'rmit/6er'vices 1601 E.'.Haielton Ave., P.O. Box 2009, Stk., CA 95201 -- FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO + EH 13-241pEV.i/Rsl EH 14-28 LlJ