91-1364 - Laserfiche WebLink

Home Browse Search

Il APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA ' Telephone (209) 466-6781 �I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I, (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. Job Address City Lot Size PM I Owner's Name Address ? ` Phone Contractor ddress ense'hlo. Phone TYPE OF WEL /PU P: NEW WELL ❑ k: , WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 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, (� 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing t ---"— '��" Specifications ��J 17 Public n Other p n Delta Depth of Grout Seal Type of Grout I I Irrigation .-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done'y r Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION IK REPAIR/ADDITION I } DESTRUCTION 111No septic system permitted if public sewer is a " available within 200 feet.) t r Installation will serve: Residence , Commercial_ Other " '^ Number of living units: n Number of bedrooms, J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑i�' Type/Mfg Capacity No. Compartments 4 PKG. TREATMENT PLT. ❑I': Method of Dis I� Distance to nearest: Well _ ._. Foundation Property Line POO1 u LEACHING LINE ❑I' No. & Length of lines Total length/size FILTER BED ❑i Distance to nearest: Well Foundation Property Line EPAGE PITS I III Depth Size Number + SU C?1;1 Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I 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 taws 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,t shall employ persons subject to workman's compensa- tion laws of California." The applicant m s c r all requiroi. pvetions. Comple d ing on ra as see side. Signed X 77� Title: Date: EPARTMENT USE ONLY Application Accepted by _..AQ C 6e� % Date Area P� kPit or Grout Inspection by Date Final Inspection by Date f Additions! Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED INFO O CASH C fD BY DATE PERMIT NO. + EH t3-241REV.i/ra51 Oc M� 11 1 t,i'7r_ 7ljJ EH 1426 1 1�'-