87-3465 - Laserfiche WebLink

Home Browse Search

}Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. ' Job Address 43 7 2' Et :9A2 City Lot Size PM Name dress �� r y �i _ -r Phone4&5-- Owner's c+ ContractnilYJ S lT` Address SQ Jtf icense No.7�_Phone / I s TYPE OF WELL/PUMP: ..NkEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTAL ION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA PROP. LINE ! FOUNDATION GRICULTURE WELL R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A A CONSTRUC SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Di"f 1�Ve11 Excavation Dia. of Well Casing (� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy y of Casing Specifications �\ M Public Cl Other ❑ Delta Depth o rout Seal Type of Grout—.--, `1 I I Irrigation —.-Approx. Depth l 1 stern Surface Seal talled by Repair Work Done ❑ Type of Pump H.P. State Work pone Well Destruction ❑ Well Diamete Sealing Material Itop 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION €1 REPAIR/ADDITION 1_1 OESTRUCTION (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: -Residence_ Commercial_ Other i 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 LEACHING LINE ❑ No. & Length of lines Tata! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �F SEEPAGE PITS 11 Depth Size Number 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, I shall employ persons subject to workman's compensa- tion laws o;Accepted the applicII fo lire ace Complete drawing on reverse side. Signed Title: Date: ;t- A �h FOR DEPARTMENT USE ONLYApplicatioby Date .: ` Area 1 Pit or Grout Inspection bK Date� Final Inspection by Date� 30 Additional Commen1s1 — +?rm I 2-2-6S5 22 qs ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71d ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE nCASH INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. 00+ EH 13-24 if1Ev.1 i H 51 / ��-3 EH 14-26 - !