87-2924 - 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 TYEAR 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. OW {} pp }-�� f Job Address *, ' City" Lot Size PM s Owner's Name 014 Address Phone f Contractor l�J'f'J'• Address Y_y.___.__ .,!/\ License No.�`i7 L(r�0 Phone 7 U I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Industrial fl Open Bottom ❑ Manteca Dia. of WA-ExcaVation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 7 Specifications ❑ Public I=l Other Cl Delta Depth of Grout Seal Type of Grout _ i I Irrigation _._Approxi Depth 1 I Eastern Surf ace`Seal'Instanad by t - Repair Work Done ❑ Type of Pump H.P. State"Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 T TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I.) DESTRUCTION INo septic system permitted if public sewer is r n vailable within 200 feet.) Installation will serve: Residence i Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet t Water table depth SEPTIC TANK ❑ T e/Mf YP 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No'R Length of lines Total length/size ! FILTER BED ❑ Distance to nearest: Well ` Foundation Property Line SEEPAGE PITS f I Depth Size Number SUMPS 0 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 i 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 followin certif 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 Califon i The applicant mus ,A i r required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ko4� Dat AArea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ 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 LAMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. Y + EH 13-24 1REV.t/A5) - EH 14-29 - I