87-2913 - Laserfiche WebLink

Home Browse Search

-41 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. ,^�y Job Address 9244 City Lot Size PM [ 11er's Name 4 OwnAddress �� A ,Phone Contractor r AddressJv" License iVo- Phone_ TYPE OF WELL/PUMP:.- NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS7SUMPS !INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications - s 1`1 Public 17 Other ❑ Delta Depth of Grout SealType of�Grout I I Irrigation —.-Approx. Depth 11 Eastern Surface Seal Installed by r a C Repair Work Done El—.%T.ype of Pump H.P. State Work Done Well Destruction ❑; Well Diameter Sealing Material (top 50'1 1 t Depth Filler Material {Below 501 A' TYPE OF SEPTIC WORK; NEW INSTALLATION I:I REPAIR/ADDITION 1.1—DESTRUCTION- -(No-septic system permitted it public sewer is 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 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 Total length/size z, FILTER BED ❑ Distance to nearest: Well Foundation Property Line r- , SEEPAGE PITS C I Depth Size Number r SUMPS Cl 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. Ir 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 of California." The applica m t call for all required inspections. Complete drawing on reverse side. 7 Signed X Title: Date: ?",] r FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area Pitt or Grout Inspection by Date Final Inspection by Date Additional Comments: _ W cN� o tk 466-6781 ❑ Lodi 3 1 ❑ M teca 8234104 It Trac 835- Applicant - Return all copies to: Environmental ligelth Permit/Servicey 601 E. Hazel n Ave., P.O. Box 2009, Stk., CA 952FEE 1 INFO AMOUNT RUE AMOUNT'REMiTffD CASH RECEIVER BY DATE'-� ' �,,PERMIT'NO. a EH 13-21(R EV.1/a5iS EH 11-28 O N