87-1377 - 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 w (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. t�r�C�v Job Address CitVii nnkEFDRDlot Size PM Owner's Name f Address A j E 1-F • V'5 l ff11 iPhone Contracto y it Address_i!4 3, I�CKE'E License No.3 Phone( `- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \� FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS — V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 7 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of.Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ` �5 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed.by_ J Repair Work Done ❑ Type of P Yp Pum r P .._ H.P. �1_ ,.State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 501--w TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION El: DESTRUCTION ❑ (No-septic system permitted if public sewer is f availabli within 200 feet.) Installation will serve: Residence— Commercial_ Other f Number of living units: Number of bedrooms { $ .: Character of soil to a depth of 3 feet: ` -' =Water—table—depth SEPTIC TANK ❑ T e/Mf YP 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ x 1 Method of Disposal Distance to nearest: WellFoundation Property Line LEACHING LINE ❑ No. & Length of lines >r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Y SEEPAGE PITS ❑ Depth Size } Number SUMPS ❑ Distance to nearest: Well - Foundation Property Line DISPOSAL PONDS. ❑ i - ------ 4 1 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.a,.! 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 followin 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 C The applica t all all required inspections. Complete drawing on re r side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT�NO. _ .+ EH i3-24 IAEV.1/n 5) EH 14-26 /J