86-358 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT , A SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA `.f Telephone (209) 466-67$1 i 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.7 �V / ;. / , s ' Job Address ity Lot Size PM � r t� Phone Owner's Name �ddress ` Contractor's Name nse o. Phone lf- TYPE OF WELL/PUMP: NEW WELL ❑ .. WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM'AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of We11 Excavation Dia. of Well Casing El Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta-.,, Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump t F H.P. State Work Done Well Destruction ❑ Well Diameter _ ! Sealing Material (top 501 ` Depth ' 'Filler Material (Below V TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (Nosbptic system m permitted if public sewer isavaN •l Installation will serve: Res'd nce Commercial— Other 3 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity___I_ No. Compartments PKG. TREATMENT PLT. ❑ --- »y h Method of Disposal , tDistance to nearest: Well Foundation Property Line 0 LEACHING LINE No. & Length of lines Total length/size FILTER BED C1 Distance Distance to nearest:` , Well c Foundation) r Property Line .SEEPAGE PITS ❑ Depth- `� �. Size � Number C► SUMPS ❑ Distance to nearest: Well r Fpundation -a ^Property Line j DISPOSAL PONDS ❑ I . 1 hereby certify that I haveprepar`ed-this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 4 rules and regulations of the San Joaquin Local Health District. ;` Home owner or licensed agent's signature certifies the II following: " 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 I 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 c r alvsw, e in ions. Complet rawing on r rse side. Title: `Date: Signed �� FOR DEPARTMENT USE ONLY A J Date—"-7Area Application Accepted by1 Y-2! Pit or Grout Inspection by _' Date'"'—_• Final Inspection by Date I� 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 h FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH l +EH 13-241REV.10/8310 EH 14-28