87-157 - 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_ 3"'i�g7{. , �, �.�♦p2- je� , (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 uric`. � T.h + >;S ;�� N 00-7 - `f Q 1 ( (( r ( a �, city a f Lot Size '� FM Job Address � - j Owner's Name i Address b L Phone ` Contractor's Name License No. ��7 3Z- Phone- >4-7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 11, - SEWER LINES '� L+° DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial UloaP en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing li�-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation a9 I-Q?L4pprox. Depth '.44 ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump �� H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 F Depth Filler Material {Below 501 4 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION D (No'Is pti sywittem permitted if public sewer isava { installation will serve: Residence Commercial_ Other 1 Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth Ca SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments '1 Method of Disposal PKG. TREATMENT PLT. ❑ "^►� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size . . FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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. 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 QQ 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 must call for all required=Inspens. Complete drawing on reverse side. Title: Signed Date: f g DEPARTMENT USE ONLY A R Y Application Accepted b Date ` Area "*k y B _ Pit or Grout IIJ t-ii�n Date Final Inspection by _ Date Additlona,ConSmen�ts: Waa f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823- ❑ 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 REMHEDW RECEIVEE18Y ,,DATEPERMIT"NO.1NF07 %^� S 7 .+EH 1324{REV.10/831 1 EH W28 a