87-354 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (200) 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 '73 City Lot Size PM Owner's Name M �< 1R U e�e5� Address 5Ci� Phone - Contractor � r Address �� _License Na. Phone r � r TYPE OF WEL /PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ w DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . ❑ Industrial t ❑ Open Bottom ❑ Manteca Dia. of-W6W Excavation Dia. of Well Casing %"❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing d Specifications * © Public ❑ Other * ❑ Delta Depth of Grout Seal Type of Grout `❑ Irrigation --- Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well biameter Sealing Material (top 501 I Depth Filler Material (Below 501 F '� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION WO�DESTRUCTION ❑ (No septic system permitted if public sewer is x "'available within 200 feet.) ` Installation will serve. Residence A— 'Commercial— Other- Number of living units: „1 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. LJ Distance I �. Method of Disposal i 1 Distance to nearest: Well' Foundation Property Line LEACHING LINE �" 141,N0. & Length'of line's Total length/size 90, FILTER BED ❑ Distance to'nearest: Well IDfi Foundation Property Line�� # r I i SEEPAGE PITS ❑ Depth Size Number - SUMPS . Distance to nearesf:,.._,..Well Foundation Property Line DISPOSAL PONDS ,"❑ hereby certify that l 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`Cocal-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."Contractors 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." f .E_ f The applicant must call for all required inspections. Complete'drawing on reverse side. '" Signed X_ 04 Title:—A,,!5 � Date: FOR DEPARTMENT USE ONLY Application Accepted by : Date 1 7 Area t Pit or Grout Inspection by Date • Final Inspection by Data Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFOE6,NTFEE DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO.' ♦ EH 13-24IREV.1/asl t " o . t7EH 14-28 o t> lg 7—�J