87-3488 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 4 1601 E. HAZEL TON 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. AJob Address City Lot Size � `z c? PM Owner's Name ss J_ Phone ,Y6 - I• Contractor r d ess' ��= License No. !, d��._.Phone 'L S �2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El UMP-INSTALLATION ❑ a -SYSTEM REP AI "❑' ' 'OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL CON UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a. o e Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Depth of Grout Seal _ Type of Grout 6 L ❑ Irrigation Approx.. Eastern w., -,.,,,,,Surface Seal Installed by- Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing.Matefial atop 50'1 _ Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADJJTIO DESTRUC ION (NDseptic system permitted if public sewer is T(/') available 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 SizeNumber �. SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 the performance of the work for which this permit is issued, I shall employ persons su_bject to workman's compensa- tion laws of California." The applican ust call for all req d inspections. Complete drawing on reverse side. Signed Title: Date:Jr �{0. (� FOR DEPARTMENT USE ONLY t Application Accepted by !" t Cly Date Area �D 4 Pit orIGroutInspection by I Date Final In�paction by Date Additional Comments: � 1fJF + ❑ Stk -466.6781.-.-.—❑ Lodi 369-3621 - - ❑ Manteca 823-7104- ❑ Tracy 835-6385 € Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 IN O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. + EH 13-24(REV.1/85) EH 14-28