87-65 - Laserfiche WebLink

Home Browse Search

1 I APPLICATION FOR PERMIT ' t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 ' City Lot Size PM Phone Owner's Name Address Contractor Address �. icense No.� Phone TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �°` DISPOSAL FLD. PROP. LINE FOUNDATION r AGRICULTURE WELL -i' OTH L PITS/SUMPS INTENDED USE _.TYPE OF WELL PROBLEM AREA CONSTRUC PJrC1F1GATVONS ❑ Industrial ❑ Open Bottom ❑ Manteca Well Excavationes+ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Speccations ❑ Public ❑ Other elta r Depth of Grout Seal Type of Grout ❑ Irrigation �4ppr epth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ of Pump _^ H.P.` — .State Work Done ! .Well Destructio Well Diameter Sealing Material (top 511 Depth Filler Material (Below 511 TYPE OF SEPTIC WORK: NEW INSTALLATION- REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is F r available within 200 feet.) Installation will serve: Redente Commercial= Other Number of living units: 7 Number f b rooms Character of soil to a depth of 3 feet: �r'j�' '• — Water table depth SEPTIC TANK a Type/Mfg 01, Capacity No. Compartments PKG. TREATMENT PLT. J Method of Disposal Distance to nearest: Well .. Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines r Total length/size Z 70 �. FILTER BED ❑,.,Distance to nearest: Well Foundation Property Line �r 3. SEEPAG PITS ❑ Depth ` Size_: X X Number UMP ❑ Distance to nearest: 1 ,Well Foundation Property Line ,MJps / ?�[? elvf I7rc 2 !, s wee-e, I fl5�d/ /frFn�?wr s df re rsr� DISPOSAL PONDS O r 16��7 � � 1 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performanceof the work for which this permit is issued, I_shali_empioy_persons subject to workman's compensa- tion laws of California." g , The applicant rqust ca for squired ' spections. Comple drawing on reverse side. Signed Title: Date: + 3 t FOR EPARTMENT USE ONLY i ! e Application Accepts y Date Area f� Pit or Grout knspec y ate -v Final Inspection by Date ` Additional Comments: ❑ Stk 466-6781 ❑ Lod 369-3621 CI Manteca 8,23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 , FEE AMOUNT DUE i AMOUNT REMITTED CASH RECEIVED BY DATE 4 PERMIT NO._ INFO a + EH 13-2,4(REV.1/a 5) f Yb,( iS' ~• EH 14-28 / I 1