87-2064 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA IND �} � 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 d .. City Lot Size PM I i Owner's Name Address \ Phone c. Contractor t Address 191License No. Phone TYPE OF WEL UMP: NEW WELL ❑ WELL REPLACEMENY❑ DESTRUCTION ❑ s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE EA REST: SEPTIC TANK '-- SEWER LINES DISPOSAL F PROP. LINE FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS INTENDED USE TYPE L PROBLEM AREA AUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy . a of Casing k Specifications —. I'l Public ❑ Other F1 Delta Depth of Grou i E Type of Grout I 1 Irrigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ; Type of Pump H.P. State Work Done Well Destruction - "El `.-Well'Diameter Sealing Material (top 50') Depth Filler Material (Below 50')y ' I TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 "REPAIR/ADDITION (.I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of Iiving units: Number of bedrooms Character of soil to a depth of 3 feet: + Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ y C l Method of Disposal Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. & Length of lines. Total length/size FILTER BED ❑ Distartcexto.nearest: # Well Foundation Property Line ,F. SEEPAGE PITS I 1 Depth Size Number t SUMPS ❑ Distance to nearest: Well ,Foundation Property Line 1 DISPOSAL PONDS ❑ I hereby certify that I haveprepared 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applic mu Acaloral,11,,Iquired inspections. Complete drawing on.reverse.side. Signed XTitle. Date: RTMENT USE ONLY Application Accepted by _4 Date 437 Area i Pit or Grout Inspection by Date ,Final Inspection by Da Additional Comments: �"�" ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEEAMOUNT DUE AMOUNT REMITTED CI( 'RECEIVED BY DATE PERMITNO. INFO CASH ' r EH 13-241pEY.rinse �� /� w �g „� ! EH 14 28