87-2519 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMITS. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA WD Telephone (209) 466-6781: ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) - >ti Application is hereby made to the.San Joaquin Local Health District for a permit to construct and/or install the work herein described. This a plication"i .Local Health District. 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 i Job Address A City Lot Size PM t Owner's Name r Address ve Phone Contractor ' Address License No. Phone TYPE OF LL/PUMP: NEW WELL'F1 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP NSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE FOUNDATION AGRICULTURE WELL OTHER WE PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO FICATIONS ❑ Industrial EJ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T ---Type of Casing Specifications f l Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I i Irrigation __Approx. Depth l I Eastern Surface Seal Installed by Repair Wo e L7 Type of Pump H-.P.-�-.--. - --. State Work Done Destruction Cl Well Diameter sealing Material ftop 501 Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTIO 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_- Other— Number therNumber of living units: t Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED © Distance to nearest: Well Foundation Property Line f� SEEPAGE PITS ('I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation PropertyLineDISPOSAL 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. 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "l 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 Cal'ornia." The applican t c for all required ' spe0o . Complete drawing on reverse side. k Signed X C7 Title: Date: 1 FORD ART�ENT USE ONLY Application Accepted by (� Date Area v '^7 Pit or Grout Inspection Date Final Inspection by Date / Additional Comments: LJ Stk 466-6781 ❑ Lodi '369-3621 13 Manteca -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 AM INFO ♦ EH 13-24 fREV. iK51 OUNT REMITTED K RECEIVED BY C CASH � �/ DATEty.� PERMITT''NO.O. EH 14-2$ � �l ,00 ( �1�� ./P/,