86-1625 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 31, 36 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 �1 City Lot Size PM t r Owner's Name ddress 5-1 Phone Contractor ss License No. �YlyPhone Q 7 TYPE OF WELL PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca is. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Ey Type of Casing Specifications E-1Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation prox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done 1 Well Destr ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION Or 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 b drooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Visposal Distance to nearest: Well f Foundation�!L Property'Line 4A 19 t r LEACHING LINE ❑ No. &.Length of lines ^ �y To l length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth ize Number ❑ 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: "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." The applicant us I for II req spections. Compl drawing o rse side. ) Signed Title: Date: {j4 FOR DEPARTMENT USE ONLY I 4pplication Accepted b p Date " Area �r Pit r Grout Inspection y Date L—�b inal Inspection by Date Additional Comments: ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24 1 REV.I/B 51 EH 14-26 ©� 4J 1 — �.y