87-1563 - Laserfiche WebLink

Home Browse Search

r ^' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Oe"i PERMIT EXPIRES 7 YEAR FROM DATE ISSUED .fl .tit, (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 ro LcJ ��yG / r r �fl / Citys�fl azj�zcA of Size_7Y� ,rAG o� PM Owner's Name Address ice. k i' " `i� — Phone Contractor . Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑—e,A''DESTRUCTION ❑ PUMP INSTAL LATIQ ❑ SYSTEM REPAIR❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES POSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications ❑ Public ❑ Other I elta Depth of Grout Seal Type'of Grout [I Irrigation _Approx. Dept ❑ Eastern Surface Seal Installed by a1 Repair Work Done ❑ Type of Pum} Done'— Well ! P YP P H•P� State Work Done_ Well Destruction ❑ Well Diameter s �' Sealing Material {top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑, REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is - available within 200 feet.) Installation will serve: Residence Commercial Other ! Number of living units: Number of bedrooms "` _n Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK )< Type/Mfg, I Capacity A m No. Compartments PKG. TREATMENT PLT- ❑ Y y Ay,, , ` "f `Method of Disposal [' Distance.to nearest: Well Foundation `' L Property'Cine q1T L r Y LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel! Foundation -Property Line. " SEEPAGE PITS Dept Size ' Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ., F DISPOSAL PONDS ❑ t 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 certifies the following:"I certify that in th&performance of the work for which this permit is,issued, I shall employ persons subject to workman's compensa- tion laws of California." 1 :7 The applicant must call for all required inspections. Complete drawing on reverse side. Signed X :I�A) Title: 'Date'; ! FOR DEPARTMENT USE ONLY Application Accepted by Date —a" — Area �(} Pit or Grout Inspection b00 I we Final Inspection by Date i Additional Comments: V 0LE ,r' .4_ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE - � AMOUNT REMITTED OK RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.I/H 5) EH 1428 T �