87-1754 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �., 1601 E. HAZELTON AVE., STOCKTON CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUEDA (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. }Jab Address e }' Citot Size PM Owner's Name �� -Clr� - Address ( V Z'�V _ - / 1_y��_ Phone T 0 '`fir ,ContractorAddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION-.❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK R SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS 'r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI CIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia ell Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other a Depth of Grout Sea] Type of Grout I I Irrigation __Approx. I I Eastern Surface Seal Installed by Repair Work Done ❑ T ump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material Itop 501 ]J Depth Filler Material (Below 50') j TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REP AIRIADDiTION I ] OESTRUCTIOINo septic system permitted if public sewer is JI ailable within 200 feet.) Installation will serve: Residence_-Z 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. CI ��0-Gc 0 IF Method of Disposal Distance to nearest: Well Foundation 3 Property Line -76 1 LEACHING LINE No. & Length of lines a I Total length/size i FILTER .BED. ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depths _Size Number i SUMPS Ll Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ 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: "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 of 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." b The applicant ust call for all requir inspections. Complete drawing on reverse side. R f Signed X Title: 0'l_.Q� Date: J FOR DEPARTMENT USE ONLY (fin Application Accepted by Date Area D Pit or Grout Inspectio Date Final Inspection by Date Additional Comments: ON 63 JGS ,t Z S i ,4 �- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-63$5 If Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE` C INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE��yy� PERMIT NO. + EH13-24IREV.i/H 51 � EH 14-28 •3 / k