87-1047 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA —'Telephone (209) 466-6781 PERMIT EXPIRES'1 YEAR FROM DATE ISSUED .(Complete in,Triplicate))1t..�'4 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 Addre L�'� T: S �, .. Y. N Cityl4�Lot Size j PM Owner's Name Address 4Y Phone Contractor Address License NO, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D L P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLD. PROP, LINE } :-- FOUNDATION AGRICULTURE WELL O PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM A UCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ ca Dia. Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casin Specifications ; ❑ Public r ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation --Approx. Depth ❑ Eastern Surface.Seal Installed by !!! Repair Wo one ❑ Type of Pump H.P. State Work Don Well Destruction ❑ Well Diameter Sealing Material Itop 50'I Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK:. NEW INSTALLATION EJ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence c'Commercial._ Other i Number of living units:' Nurn6e'r of bedrooms � Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments F PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation i Property Line ` LEACHING LINE ❑ No. & Length of lines I 'Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS ❑ Depth Size• t n SUMPS- ✓� a - Number f ❑ ,Distance to nearest:' - Wel! - _:Foundation — ,.Property Line DISPOSAL PONDS ❑ i 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. i ' _ . , .r Home owner or licensed agent's signature certifies the following; I certify that in the t " Y performance of the work for which this permit is issued, I shall not I employ any person in such manner as to become subject to workman's compensation laws of California,, Contractor's hiring or sub-contracting signature j certifies the following:"I certify that in the performance of the work for which this permit is issued, I shail employ persons subject to workman's compensa- tion laws of California." F r q' is k Th lica t call foyll r pe tions, Complete drawing on reverse side. ""��1, ignad X Ti le: l Date: car. ARTMENT USE ONLY r Q { Application Accepted by j - "-. - �-; Date �� 1� a - •,�..... ..-_�- Area P Pit or Grout Inspection pate Final Inspection by Date Additional Comments: 4 -�-A-- ,..❑_Stk 4fi6�6781_ _ ❑ Lodi 369-362.1 . _10-Ment _623-7104. _E1_Tracy_835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9_5201 ,. FEE AMOUNT DUE AMOUNT REMITTED t INFO CASH RECEIVED BY DATE PERMIT�NO. � y a + EH-18-241REV. g/yn�� 1 EH 1¢28 J