87-745 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT CC � 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) N',- Application W� 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 y.� ��/ (� �- _5 �� City FXk15942ot Size PM j Owner's Name CO Addressy S �� h��4 .S'Atid Phone s Contractor Address License No. Phone ' TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSA D. PROP. LINE FOUNDATION AGRICULTURE L 0TH ELL PITS/SUMPS i4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU ION CIFICATIONS ❑ Industrial Q Open Bottom ❑ Manteca Dia. of We ovation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack Ll Tracy Typ Casing Specifications ❑ Public El Other ❑ Delta epth of Grout Seal Type of Grout 17 Irrigation --Approx. Depth LJEastern Surface Seal Installed by� Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 19 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ -DESTRUCTION (No septic system permitted if public sewer is S - - available within 200 feet.) Installation will serve: Residence-)(, Commercial— Other I Number of living units: Number of bedrooms Character of soil to a dept of 3 feet: Water table depth SEPTIC TANK e Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length size FILTER BED ❑• Distance to nearest: Well L Foundation Property Line if SEEPAGE PITSDepth �� Size Number ,1 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,1 shall employ persons subject-to workman's compensa- tion laws of California. . S I t must ca or all required inspections. Complete drawing on reverse side. Signed X ��/ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by 'Q Date `�� 9 Area Pit or Grout Inspection Date Final Inspection by Data Additional Comments: {* lx ` /Q c. ❑ Stk 466-6781 ❑ Lodi 369-3621 I] 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 C 3 RECEIVED BY DATE PERMIT NO. + EH.13-241REV.17851 EH14-28