87-1738 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED . :.I (Complete in Triplicate) I. 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. /r��f �. Job Address eX�{rJ�1 � Plea City of Size /ZSXPM Owner's Name r ��! Address Phone i Contractor .Address -T m License No. 68e— Phone TYPE OF WELL/PUMP: N WELL ❑ WE_LL,REPLACEMENT ❑ DESTRUCTION ❑ I—PUMP INSTALLATION ❑ - -SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS D. PROP. LINE 4 { FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca na. of Well Excavation Dia. of Well Casing ❑ Domestic/Private i ❑ Gravel Pack Cl Type of Casing Specifications i ❑ Public - [ ❑ Other i""- Delia Deptli of Grout Seal Type of Grout ❑ Irri atioh ___,�1 k s g � pp epth ❑ Eastern Surface Seal Installed by (`} s Repair Work bone ❑ T of Pump H.P. State Work pone Well Destruction{ Well Diameter Sealing Material (top 501 I F Depth Filler Material (Below 50') ( # l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION � (No septic system permitted if public sewer is a available within 200 feet:) Installation will serve Residence_ Commercial_ Other $ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: >. Water table depth x SEPTIC TANK '. Typal Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line� J _ a LEACHING LINE ❑ No. & Length of fines Total length/size i FILTER BED ❑ Distance to nearest: - Well Foundation !' Property Line SEEPAGE PITS (❑ `"Depth r I Size Number ' SUMPS ❑ 'Distance to nearest: Well Foundation IProperty Line 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 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 t 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;he performance of the work for which this permit is issued,I shall employ persons subject to workman's-compensa- tion laws of California.' , The applicant �st call-for.all to ired '1 spee tion, Complete drawing on rev ide. Signed `i/� iiia: �' /�fC� _ Date.J/ 1 g. FOR DEPARTMENT USE ONLY �'^ Application Accepted by Date b^� Area S _ S Pit or Grout Inspection Date Final Inspection by DatA �1 r , Additional Comments• ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835- C 4.6 be- Applicant - Return all copies to: Environmental Health Permit/Services 1 E. Hazelton Ave., P.O. Box 2009, St 95201 FEE INFO AMOUNT DUE AMOUNT R'E'MITTED CK H RECEIVED BY «✓ DATE PERMIT NNo. + EH 13-24{REV.I/n 57 -7 EH 14-26