87-2265 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQU'IN LOCAL HEALTH DISTRICT (� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VY•EAR FROM DATE ISSUED } (Complete in Triplicate) l 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 r Local Health District. AV f Job Address � ! ' City Lot Size/1-5-M&S PM Owner's Name - rh� Address " `-rS " Phone s "Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES OSAL FLD: PROP: LINE FOUNDATION AGRICULTURE W OTHER WELL : PITS/SUMPS } INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial 7Gravel n Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Pack Tracy r Type of Casing Specifications ❑ Public r ❑ Delta Depth of Grout Seal $ Type of Grout t i _ rox. Depth i I Eastern Surface Seal Installed by " I I lrrigauon App d Repair Work Don _ Type of Pump H.P. State Work bone_ Well Destruction ❑ Well Diameter SeAling Material Stop 501 ; Depth Filler Material (Below 501 a TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence Commercial— Other ` Number of living 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. ❑ m Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r :{ FILTER BED ❑ Distance to nearest: Well Foundation Property Line - SEEPAGE PITS I l Depth 1 Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ± f 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 t 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; 1 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 inspections. Complete drawing on reverse side. Signed X Title: _ �( Date: t ® FOR DEPARTMENT USE ONLY. Application Accepted by _ `^� " Date v"'��— U� Area Pit or Grout Inspection. Date .Final Inspection by! _ "Date . v I, Additional Comment ❑ $tk 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 95291 j� FEE { INFO AMOUNT DUE AMOUNT REMITTER GK R RECEIVED BY DATE PERMIT ND, r t r'EH-13-21(REV.r/ns) j EH 14-2a