87-830 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT // / - 1601 E. HAZELTON AVE., STOCKTON, CA (`) a�Cl- Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heiaby 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. 7 Job Address mm City Size PM r r Owner's Name nn L Address I L.o1 Phone Contractor%I ITLT f ,A-C F I1. ' Address 2)6'0 icense No. Phone S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DIST �ST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava i �Dia. f Well Casing ❑ Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing fications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal of ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ -DESTRUCTION f.614 tic system permitted if public sewer is avai a within 200 feet./ Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg }" Capacity--' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 ❑ j 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 ce '' s the fallowing: "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 la f California." The pplicant st all for a �'redpec ns omplet drawing on reverse si c-- Signed Title: I Date 3 R DEPART NT USE ONLY �) Application Accepted by - Date Area tJ Pit or Grout Inspection by Date //Final Inspection by Date Additional Comments: �!_ Gf4�tl��.S ❑ Stk 4W6781 ffLodi 369-3621 ❑ Manteca 823-7104-- ❑ Tracy 8354w) — T-- - - 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 CK RECEIVED BY DATE PERMIT'NO. INFO EH 13-24+ (REV. 5) V / L:340] EH 14-28 VVV i