87-4250 - 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. Job Address t City Lot Size PM Owner's Name Address Phone Contractor ddress License No.0 Phone TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR [:1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS EJIndustrial If Open Bottom ❑ Manteca Dia. of Well Excavation El Domestic/Private 13 Gravel Pack ❑ Tracy T Dia. of Well Casing Type of Casing Specifications Ll Public ❑ Other C] Delta Depth of Grout Seal r ❑ Irrigation _Jq TYI�of Grout ---Approx. Depth EJ Eastern Surface Sea! Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Wel! Destruction El Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ` available within 200 feet.) Installation will serve: Residence, Commercial_ ther Number of living units:A_ Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK 1:1 Type/Mfg Water table depth Capacity No. Compartments PKG. TREATMENT PLT. E7 # Method of I Distance to nearest: Well Foundation Property Line_. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ell Foundation �� Property Line SEEPAGE PITS ❑ Depth ze Number P ❑ Distance to nearest: Well Foundation ISPOSAL PONDS ❑ Property Line 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 applicant mu call r all requi n ctions. Comple drawing aside. Signed Tte: U FOR DEPilARTMENT USE ONLY r. Date: Applic n Accepted by Date 2 �� ////// .J Area r rout ins 9 n by � Date)2� Final Inspection 6Y 3 Date Additional Comments: ❑ Stk 466-6781 " ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO j`�� CASH RECEIVED BY DATE PERMIT`NO. +EH T426 IflEV.1/85) L V�}�7�Qo c .,�, .t� J v. g"-� a