87-2056 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 ,PERMIT EXPIRES TYEAR 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. �c�0 City Lot Size PM a Job Address _ '` 1�1 _ Address Phone Owner's Name � �j Contfacto�,ia '-! Address License No. �I Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CT DESTRUCTION ❑ s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS € ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done-_ = Well Destruction 0 Well Diameter Sealing Material Itop 501 Depth f Filler Material (Below 601 TYPE OF SEPTIC WORK: NEW INSTALLATION 1] REPAIR/ADDITION I ]- DESTRUCTION 1 INo septic-system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 4 Commercial_ Other ,C1 Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: ' SEPTIC TANK ❑ -TypelMfg""""�'" Capacity 7 LLT No. Compartments j PKG. TREATMENT PLT. ❑ Method of Disposal s Distance to nearest: Well Foundation Property Line i LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED . ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth Size �� ` 't R Number SUMPS Ll' Distance to nearest: Wel! �. Foundation Property Line f DISPOSAL PONDS 0 I hereby certify that 1 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. 1 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: 111 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 applican ust all for all required inspections. Complete drawing on reverse side. �J Signed Title: Date: � �` l FOR DEPARTMENT USE ONLY ' Application Accepted by Date 2 2 Area Pit or Grout Inspectionnb � Date v.- Final Inspection by_ _ _ Date- Pit ate 7 Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 0 Manteca `823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 M { " .. J FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO _ ` . EH 13 -24 i/Kal 3 [ -� � -2 1�7 EH 14.28