90-518 - Laserfiche WebLink

Home Browse Search

vt u rr r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'f 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 weVpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address V City L t Size PM Owner's Name Address Phone Contractor + ass icense No Phone �� Phone�/ z TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ YSTEM REPAIR ❑ OTHER 1-1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Di f Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp of Casing Specifications I`I Public f_n Other ❑ Delta De h of Grout Seal Type of Grout I i Irrigation --Approx. Depth I I Eastern S 'ace Seal Installed by a Repair Work Done ❑ Type of Pump H:P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material TYPE OF SEPTIC WORK: NEW INSTALLAvON I 1 REPAIR/ADDITION I DESTRUCTION I 1 (No septic system permitted if public sewer is +// available within 200 feet.) Installation will serve: Residence Commercial ther Nurnber of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - U C1 No. Compartments PKG. 'TREATMENT PLT. ❑ _ ,_ Method of Dispos -- Distance to nearest:, well ,� `—foundation Property Line U ' (/ LEACHING LINE Cl No. & Length of lines d To al length/size D FILTER BED ❑ Distance to nearest: Well Foundation Property Line A SEEPAGE PITS I I Depth Size Nu er 01 SUMPS L] Distance to nearest: Well Foundation 3o Property Line Zd 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."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." The applican must call fo all required inspections. Complete drawing on reverse side. -3 XZ�f Signed X Title: Date: c� FOR DEPARTMENT USE ONLY / 4j / Application Accepted by Date C [ t,t Area e 57 Pit or Grout Inspection by Date Final Inspection by Date �U 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, Stk., CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 1 .21[REV. /x51 EH 114-39