87-3216 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZE 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. 1862 for well/pump and the Rules and Regula ions of the San Joaquin Local Health District. ��s•= e / �,J� I Job Address CityZ--7�0,aot Size SD X Zoo PM IF p011 ,Owner's Name , f Address _ o r7/ Phone 4e� Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION F1 �t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD: PROP.,LINE- `V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Welt Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications " t`l Public n Other n Delta Depth of Grout Seal Type of Grout r I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1- Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION DESTRUCTIONX IIVo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence��Commercial_ Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth' SEPTIC TANK >L Type/Mfg Capacity 4No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lirie' LEACHING LINE ❑ No. & Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line i ., SEEPAGE PITS I I Depth Size Number tt� SUMPS Ll Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all re wired inspec'ons, Complete drawing on reverse side. Signed X Title: �� _ Data: t FOR DEPARTMENT USE ONLY Application Accepted by J Date Area + Pit or Grout Inspection by by Date Fi�/al Inspection byf� Date Additional Comments: ❑ Stk _466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Trac/865-61W. sApplicant'- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 '� ' v. INFO� AIuIOUNT DUE AMOUNT REMITTED CASH. RECEIVED BY .D E PERMIT NO.