87-2003 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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. �, i9L Job Address �/��] �C � V • - _______ City Lot Size R4, PM Owner's Name , �L7I` Address R' t� �tf + E'Zc&_T Phone Contractor Address License No, Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO Ni ! ST.: TANK SEWER LINES DISPOSAL FLD. ROP. LINE DATiON AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF PROBLEM AREA CONSTRUCTION SPECIFIC�,Tf S ❑ Industrial ❑ Open Bottom Ria. of Well Excava Dia. of Well Casing fl Domestic/Private ❑ Gravel Pack ❑ Tracy g Specifications \V 1-1 Public Cl Other ❑ Delta th of Grou Type of Grout I I irrigation Approx. Depth I i Eas Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work �] Well Destruction ❑ Well Dia r Sealing Material (top 50') D pth Filler Material (Below 50'i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is ��// available within 200 feet./ r Installation will serve: Residence?ti Commercial_ Other 4ater Number of living units: Number of bedroomsCharacter of soil to a depth of 3 feet: table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: e I ound tion 7— Property Line LEACHING LINE No- & Length of linesr!!!nt ' Total length/size FILTER BED ❑ Distance fo.nearest: Well Foundation Property Line�� J SEEPAGE PITS I I Depth 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 as 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, I shall employ persons subject to workman's compensa- tion laws of California." The applican ust call for all req "ed inspections. Complete drawing on reverse side. �! Signed X �Jfr t~ Tit[e:�. �+E � - _ Date: 15 _/�~r7� FOR nEPARTMENT USE ONLY Application Accepted by ` Date a� (^/y+ Area '4111— Pit OPit or Grout Inspection byate Final Inspection bye/�� a'i Dat O � Additional Comments: A01- El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 A�S,HIRECEIVED BY DATE p PERMIT NO. ry + EH 13-24(REV.1/951 A ��---- 3`+� EH 1428