87-1712 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 .. f � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 3 .ti j (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit toconstruct fowell/d/or ump and the Rules and Regll the work herein ulations of cation is the.This San'Joaquin pP made in compliance with San Joaquin County Ordinance No.549 for sewage or No. �P Local Health District. p G: Y aw ��7 � City /7� Lot Size A PM Job Address t / J F /�, ISO Z/g T�E�X��ig� �/�y Address TS'/ �Cf�,Phone v �� Owner's Name Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EI Dill'' PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE INTENDED USE TYPE OF WELL PROBLE A CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Specifications 1 VDomestic/Private ❑ Gravel Pack L3 Tracy Type of Casing ❑ Public 71 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation prox1Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ pe of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material {top 50') Depth l Filler Material (Below 501mi ! per TYPE OF SEPTIC WORK: NEW 1NSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ElavlailabPe{with ne200 feettted if public sewer is . { 4 Installation will serve: Residence_61� Cornmercial Other Number of living units: Number of bedrooms Water table depth ` Character of soil to a depth of 3 feet 0 No. Compartments SEPTIC TANK Type/Mfg Capacity Method of Disp PKG. TREATMENT PLT. ❑ I "' Property Line osal Distance to nearest. Well Foundation i Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED d Distance to nearest: Well Foundation Size Number I SEEPAGE PITS s +❑ Depth property Line 1 SUMPS ❑ Distance to nearest: well Foundation DISPOSAL PONDS 3 1 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: "1 certify that in the performance of the work for which this permit is issued, I shall not I of California." Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject to workman's compensation laws 3 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."1. a r The applicant must call for all required inspections Complete drawing on reverse side. A , �u ��' f 4 Title: Date: f� Signed , ^ 5 F6R DtPAATMENT USE ONLY i " _� Date ,area Application Accepted by 11 Date Date Final Inspection by iPit or Grout Inspection by n { Additional Comments: d 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835 Stk., CA 95201 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, CK#' RECEIVED BY DATE PERMIT NO. FEE I AMOUNT DUE AMOUNT REMITTED CASH INFO � + EH 13-24{REV. EH 1420 ,;