87-371 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 7 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. Job Address AG'i a.:Pit)E .• City KA"W-G A_ Lot Size PM Owner's NameS20Vr SAW D S OAddress 1101t d Apt Phone 110 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ / DESTRUCTION ❑ PUMP INSTALLATION ❑ SYST.I�M REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE + FOUNDATION AGRICULTURE IIWEL OTHER WELL PITS/SUMPS INTENDED USE 7' ELL( AREA CSO RUCTION SPECIFICATIONSTE ?J ❑. Industrial. _ Open Bottom . .. annrl teca D'iae"61.Well Excavation Dia. of Well Casing j O Domestic/Private ❑ Gravel Pack ❑ Tracy t Type of Casings Specifications i ZP c '- ❑ Other- ❑`Delta Derout eal pth of G `�"` �""""'�'"�" Type of Grout rngation 17—VLApprox. Depth ,❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Puml5 uW#.vim H.P. 46 State Work Dohe Well Destruction ❑ Well Diameter Sealing Material (top 501 .�� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION L7 (No septic system permitted if public sewer is f 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 C „rSEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal - t ( Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size - t..' > FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 r employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify 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." The applicant call for all required i spections. Complete drawing on reverse side. SignedTitle:: s_� Cr? � Date: 7 Zg FOR DEPARTMENT USE ONLY Application Accepted by Date J"a''�� Area Pit or Grout Inspection by Date Final Inspection by_ ate v Additional Comments: ❑ Stk 466-6781 Ci Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354i3%) Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. + EH 1321(REV.t/a5) EH 1428 /�