88-1033 - Laserfiche WebLink

Home Browse Search

3: APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �S 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. 1662 for weii/pump and the Rules and Regulations of the San Joaquin Local Health District. ,1 (Job Address fy City Lot Size PM wner's Name ress .Z. Phone ontractor Address License No. Phone TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INST,,L ION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP PROP, LINE FOUNDATION ICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS \ ❑ Industrial ❑ Open Bottom ❑ Mante Dia. o I Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications r"l Public ❑ Other Cl Delta Depth of Grout Seal T \ ype of Grout ± I I Irrigation A x, Depth I I Eastern Surface Sea! Installed by f r` Repair Work Done ❑ pe of Pump H.P. I - State Work Done ,Yell Destructio Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ; TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION ( I DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence Commercial available within 200 feet.) 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. ❑ 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 Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LlDistance to nearest: Well F DISPOSAL PONDS ❑ Foundation Property Line 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 followin t employ an g- "I certify that in the performance of the work for which this permit is issued, I shall not p y y 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 Californi ' The applicant I for all re fired in c-on amp) to drawing on;;Vide' rgned X Title: G� Date: , FOR DEPARTMENT USE ONLY Application Accepted by W Date Area Pit or Grout inspection by Date Final Inspection by Date S fo Additional Comments: 42 I20 e ❑ Stk 466-6781 L7 Lodi 69-3621 Cl Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE p i CK f INFO PERMIT'NO. +.EH 13-24(REV.Iiwsl -EH 14-26 g �� `