87-2677 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN -LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON.AVE., STOCKTON, CA Telephone {209) 466-6781 r PERMIT EXPIRES 1 YEAR,FROM DATE ISSUED ��,• t :y "„ 4 (Complete in Triplicate); r.��`t .��3t , .? 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. 1662 for well/pump and the Rules and.Regulations of the San Joaquin Local Health District. h yyx r:. Q yl"" , ll!r Y s - nil- - a Job Address 1J City Lot SizeJo PM Owner's Name Address �O Phon e3�� Contract Address License No6�7 Phon Z6 7-6 TYPE OF WELL/PUMP: NEW WELL ❑ ':WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM,REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLO. PROP. LINE T ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 ---1 Type of Casing Specifications ❑ Public ❑ Other ❑,Delta t Depth of Grout Seal Type of Grout ❑ IrrigationiA { Approx.EDepth 11. e�Cl iEastern Surface Seal Installed by Repair Work_Done O Type of Pump H.P. State Work Done Well Destruction, Weill Diameter' Sealing`Material Itop 501 — y J Depth — Filler Material IBelow 501 TJYPE OF'$EPTI,C_W.O,RK: NEW INSTALLATION REPAIR/ADDITION ElDESTRUCTION El (No septic system permitted if public sewer is available within 200 feet.) Installation will srve: r Residence-t/Commercial-. Other` Number of living units.:.!I Number of bedrooms r 1 .. ' Character of soil to a depth of 3 feet Water table depth SEPTIC TANK Type/Mfg Capacity/�ol�d No. Compartment fi� 'Yx PKG. TREATMENT PI_'❑ I� l :* e r Method of Disyosal_k. Distance to nearest:,j Well t��- Foundation lQ Property Line LEACHING LINE 4r No. & Length of lines �` r Total length/size l K FILTER.BED s❑ Distance to nearest:' Well Foundation --Property Line jp SEEPAGE PITS FIS Depth r Size - N_umber SUMPS EX.Distance to nearest: Well 1<96 Foundation f� Property Line;� T 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 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 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 applicant ust call for VqAu�;,re nspections. Complete drawing on reverse -d Signed X Title: .� bate: II FOR DEP TMENT USE ONLY I r Application Accepted by Date `-' Area k it r Grout Inspection by' Date Final Inspection by E Additional Comments: l i j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6366 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.:Box 2009, Stk., CA 95201 FEE gMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, INFO CASH f + EM 13-24(REV.'iY R 5) EH 14-26 i