87-1228 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 4 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. _ 1 Job Address City Lot Size PM Owner's Name Address --' Phone Contractor Address %S_fj!�2 /��-:C--g License No. Q Phori Lm;), TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ � ! PUMP INSTALLATION ❑ _— SYSTEM REPAIR ❑ OTHER ❑ _ . q DISTANCE TO NEAREST: SEPTIC TANK . -SEWER-LINES "'�'—DISPOSAL FLD PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial -,y,. ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public�Y�.. ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destructionq'�❑ :!Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 3 TYPE OF„SEPTIC-.WORK: 4NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system-permitted if public sewer is available within 200 feet.) Y, ;','Installation will serve: Residence_ Commercial_ Other *+.� Number of living 'units: Number of bedrooms a Character of soil to a depth-of,3 feet:- - - ,,Water table depth I '"SEPTIC TANK ❑ ,Type/Mfg,- ti. Capacity No. Compartments TREATMENT PLT. ❑ "�; ,` Method of Disposal i �Drstance to nearest: Well -— -- Foundation f Property Line LEACHING LINE o=& LengtFi ofuline§ a.J Total length/size FILTER BED ❑ Distance toen arest: Well Foundation Property Line /--� SEEPAGE PITS Uln, Dept �'`. e�� z� ,�( � Number SUMPS f I._L.I 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS .❑ I hereby certify that'l 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. + (mow l 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 applicant m t cal for all requ'ed i specti s.:Complete drawing on reverse side. Signed X Title: A f./ ./�� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Date Final Inspection b Date y � Pit or Grout Inspection by P Y Additional Comments: r�V1 r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CCH RECEIVED BY DATE PERMIT NO. INFO /� �) PE a EH 13-24 IHEV.t/H 51 !� � �� EH 14-M // L! 666 1 - ' � R