87-1039 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4,015 1601 E. HAZELTON AVE., STOCKTON, CA 'i "Telephone(209) 466-6781 r; r , t,,,..�•.., ,�^ �, a � r r;..,' PERMIT EXPIRi=S 1 YEAR FROM ,DATE ISSUED >> ; .f#' ,.(Complete in Triplicate),, ,tp , A alth madecation is Application in com compliance with Sano the San Joaquin Joaqu n County Ordinalnce No.District549 for sewage or permit No 1862 forcwelltpump and.the Rules and IR gulations of he San Joaquin made in c P y , ._ - r. j Local Health District. #. ..� • 1 y• ,fi* . '' "" �f`,7 •� f Lot Size PM I � City l Job Address i rens Owner's Name _ r r License No. Phone Contractor Address ' i { TYPE OF-WELL/PU NEW WELL E3 WELL REPLACEMENT El PUMP ❑ t PUMP INSTALL/JPON .❑... SYSTEM-REPAIR•-❑- _— �^"' — .OTHER--❑- DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA j CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca ! Dia. of WeIK xcavation .�/ rT e of Casing- 0 asin j Specifications El Domestic/Private ID Gravel Pack El Tracy ( Type g Type of Grout ❑ Public Ll Other ❑ Delta "Depth of Grout Seal yp 1 El Irrigation ---Approx. Depth El East Surface Seal Installed by T H p r-� s°" State Work-Done Repair Work Done ❑ Type of Pump Well Destruction ❑ Well Diameter Sealing Material.(top 50'1 a t Depth r Filler Material /Below 501- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic it stem permitted if public sewer is eet.f 1 - - Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Water table depth I Character of soil to a depth of 3 feet: 1# No. Compartments SEPTIC TANK ❑� Type/Mfg Capacity r Method of Disposal PKG. TREATMENT PLT. ❑ i Property Line Distance to nearest: Well Foundation LEACHING LINE ❑ Na. & LengtMof linTotal length/sizees _ �'- FILTER BED ❑ Distance to nearest: Wall Foundation Property Line a r V Number ` SEEPAGE PITS ❑ Depth Size SUMPS 11Distance 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: 1 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." /J� The applicant must call for al req i d i spections. Complete drawing on reverse sid . " Title: Date: _ J Signed ° FOR DEPARTMENT USE ONLY � I� F t Date 3 Vj' Area n� Application Accepted by Pit or Grout Inspection by Date Final Inspection b e Date Additional Comments: ❑ 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.O. Box 2009, 51k., CA 95201 FEE CK RECEIVED BY DATE PERMITNO. AMOUNT DUE- AMOUNT REMITTED CASH INFO \�"^ + EH 13-24(REV.1/0 5) � �+J� �� .. EH 14-28