87-2154 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a 6 1601 E. HAZE T ON AVE., STOCKTON, CA No Wi ow Wza?— "k {" Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Application is hereby made to the San (Complete in Triplicate) h„ � Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is ` made in nce compliawith San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the 5a Local Health compliance n Joaquin Job Address City Lot Size + PM Owner's Name Contractor Address 2 �� Phone I Address TYPE OF WELL/PUMP: NEW WELL ❑ License No. Phone PUMP INSTAL TION ID License REPLACEMENT El DESTRUCTION ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK S TEM REPAIR ❑ OTHER ElSEWER LIN DISPOSAL FLD. fi FOUNDATION AGRICULT AE WELL PROP. LINE INTENDED USE TYPE OF WELL `OTHER WELL PITS/SUMPS ' PAO6 MARE CONSTRUCTION SPECIFICATIONS s ❑ Industrial ❑ ❑Open Bottom y _ Q Domestic/Private ❑ Gravel PMantec Dia. of Wefl Excavation Pack FJ T � Dia. of Well Casing 1-1 Public f-1 Other fl Ype of Casing DeltaSpecifications I I Irrigation epth of Grout Seal Type of Grout Repair Work pone ❑ Type of Pump Approx. Depth I ! E em S ce Seal Installed by H.P.Well Destruction F1 Well Diameter Stare Work Done Depth Sealing Material (top ) Filler Material (Below 50')\ TYPE OF SEPTIC WORK: NEW INSTALLATION f-1REPAIR/ADDITION f I DESTRUCTION (No septic system permitted if public sewer is Commercial Other Installation will serve: Residence available within 200 feet-) Number of living units; Number of bedrooms Character of soil to a depth of 3 feet: 1 SEPTIC TANK ❑ Type/Mfg Water table depth `I 'PKG. TREATMENT PLT. ❑ Capacity. No. Compartments Distance to nearest:- WellMethod of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Total length/size r Foundation_ Property Line SEEPAGE PITS 11 Depth SUMPS Size _ Number L1 Distance o nearest: Well r DISPOSAL PONDS ❑ •. Foundation property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Paws, 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 empioy persons subject to workman's compensa- tion laws of California." The applicant must call for aft required inspections. Complete drawing on reverse side. Signed Title: � VkA_� Date: F R DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout inspection by Area�T� Date Final Ins action by Additional Comments: V Date ❑ Stk 466-6781 ❑ Lodi 369-3621 Applicant- Return all copies to: Environmental Heal haPeermit/ca Servces41601 E. Hazelton Tracy �A e., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED C S RECEIVED BY DATE t EH 13-24/REV.i i n s) PERMIT NO.EH 14-26 j r