87-924 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT V_5 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 of Size Ti d X 0'6___ PM Owner's Name __Z. I P�Q� Address Phone r Contractor Uladd—Address License No. Z?5. hone�f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT ION,_CJ.— PUMP INSTALLATION El 'SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. - ROP. LINE FOUNDATION GRICULTURE WELL OTH PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM-ARtY CONS N SPECIFICATIONS ❑ Industrial ❑ Open Bottom C1 Manteca ia. ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casi Specifications ❑ Public ❑ Other Delta Depth of Grout Sea Type of Grout ❑ irrigation �Ap epth ❑ Eastern Surface Seal Installed by Repair Work Done 01T of Pump H,P. State ork Done_ Well Destruction Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 'INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms h .I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal (tttJJJ� Distance to nearest: Well Foundation Property Line LEACHING UNE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: f 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."Contractors hiring or sub-contracting signature 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." ThQ:4mzl4can.t must call or all requir d inspections. Complete drawing on reverse side. ' Signed Title: Date: I FOR DEPARTMENT USE ONLY Application Accepted by Date 2 Area Pit or Grout Inspection by Date Final Insgrction by Date�� Additional Comments: ❑ 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 REMITTED C RECEIVED BY DATE PERMIT NO. INFO + EH 1324{REV.tie 57 EH W26 ` T t