86-1599 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601,E. HAZEL 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.' / Lot Size PM Job Address �F � Cid` Owner's Name + / Address ! 7x , f( Phone me vis Contract4GIeL4 eO Address License No., —Phone 1057 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EJDESTRUCTION ❑ 6 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by Type of Pum H.P. State Work Done Repair Work Done ❑ yp p Rep - Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted H public sewer is available within 200 feet.) Installation will serve: Residence Commercial- Other Number of living units: Number of,.be rooms Character of soil to a depth of 3 feet: a Water table depth SEPTIC TANK Wr�-Type/Mfg opacity% n y" No. Compartments rte: _ ! o Method of Disppsal PKG. TREATMENT PLT. ❑ �--�y Distance to nearest: Well Foundation Property Line— �-; LEACHING LINE i0t No. & Length of lines �T tal-length/size-&-- X i FILTER BED ❑ Distance to nearest: well –Foundation• Property Line " SEEPAGE PITS ❑ Depth Size Number . SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. 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 i 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 subject to workman's compensa- tion laws of California." I The applicant must call for all req 'ed inspections. Complete drawing on reverse PsSigned Title: Date: �• �� FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by ' '�� Date - Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO I G +EH13.241REV.5/95} EH 1428 '�