87-1491 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. HAZEL T ON AVE., STOCKTON, CA . Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,, 1 l 14 ',sit r; j7,.(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 made H compliance with San Joaquin County Ordinance No:549 for sewage or No. 18&2 for well/pump an&the Rules and Regulations of the San Joaquin � Local Health District. pp on is ` 1 � Job Address S `e" {. , r t City . .`` Cit Lot Size ALL/g2D PM Owner's Name Address - k ,� __ _ Phone Contractor Address I�S� TYPE OF WELL/PUMP: NEW WELL ❑ "M 1 License No.WPhone ,, ELL REPLACEMENT L1DESTRUCT PUMP.INSTALLATION ❑ SYSTEM REPAIR L2 ION Li j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE FOUNDATION AGRICULTURE E INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS ❑ Industrial ' ❑ Open Bottom anteca Dia. of Well Excavation- "� EJ Domestic/Private ❑ Gravel Pa El Tracy { Dia: of Well Casing ❑ Public Y ;a Type of Casing ❑ 0 r ❑ Delta ft Depth of Grout Seal Specifications ❑ Irrigation ,Approx. Depth El Eastern Type of Grout Repair.Work Do ❑ Surface Seal Installed by Type of Pump H p Wel! Druct on State.Work Done ❑""1NelI'biameter Sealing Material (top 50') r j _, Depth S Filler Material [Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION C2;.,REPAIR%ADDITION ❑ DESTRUCTION {No septic system permitted if public sewer is I Installation will serve: Residence 4 J available within 200 feet.) Commercial_ Other�4 f Number of living units: Number of bedrooms " Character of soil to a depth of 3 feet: SEPTIC TANKType/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity— No. Compartments Method of Disposal Distance to nearest: Well Foundation f � Properly Line � 1 LEACHING LINE ❑ No. & Length-of lines - _i ,.- a Foundation I FILTER BED Distance to nearest: Well i unTotal length/svize �I dation Property Line EJ SEEPAGE PITS ❑ Depth _-�Si t - Size Number ` SUMPS ❑ Distance to nearest:" Well { DISPOSAL PONDS Foundation Property Line hereby certify that I have re ' p pared application and that the work will be done in accordance with San Joaquin county ordinances, slate 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, r' - employ any person in such manner as to become subject to wI shall notorkman'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 applicant must call for all required inspection Complete drawing on reverse side. Signe X Title: �_[ ^r 77104 CrQ Date: � a2 �' .9,; j FOR DEPARTMENT USE ONLY Application Accepted by uI, � Date ` Area Pit or Grout Inspection b A Date Final Inspection by Date —— Additional Comments: - �M " r — N ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 7104835-6385 �i Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E.❑Hazel on jAve., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 'RECEIVED BYf CASH EDATE PERMIT'NO. r EH 13-24(REV. C7 C, 135 rt i �} /�