85-427 - Laserfiche WebLink

Home Browse Search

•rt APPLICATION FOR PERMIT 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 Regulations6f thhan J�a�uin Local Health district. � CA Job Address City Lot Size PM r 0 Owner's Name Address — Phone g2zContractor's Name No. L25— Phone J0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T Qf 1� DESTRUCTION ❑ PUMP INSTALLATION ❑ ' SYSTEM REPAIR ❑. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL I OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial OpenBottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Gravel Pack! ❑ Tracy Type of Casing Specifications ❑ Public E Other ❑ Delta F . Depth of Grout Seal I Type of Grout El Irrigation -Approx. Depth ❑-Eastern ♦ Surface Seal Installed by,.' Repair Work Done ❑ Type of Pump H.P. ' 'State Work Done _ Well Destruction ❑ ell Diameter Saaling Material(top 50') D pt.h - Filler Material (Below 501 TYPE.OF SEPTIC WORK: EW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is { available within 200 feet I Installation will serve: R idence—V`commercial— Other Number of living units: Number of bedrooms Character of soil to a depi h of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑. Method of Di osal (� Distance to nearest: Well_/ Foundation 1N Property Line— ?' 1 LEACHING LINE No. & Length of lines , Total length/size FILTER BED Distance to nearest: Well f `', Foundation ena_ Property Line . ' ' 01 SEEPAGE PITS Depth Siie Number SUMPS f Distance to nearest: Well Foundation Property Line DISPOSAL PONDS E` I hereby certify that I havk,, repared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of thbj San Joaquin Local Health District. Home owner or licensed ag®nt'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: "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." 1 The applicant t c all re ired ins io s. Comple wing on e rse side. Signed Title: bate: r FOR DEPARTMENT USE ONLY Application Accepted by Date ff Area r _ r or Grout Inspection by.3_� � - Date Final Inspection by Date Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK CASH RECEIVED BY DATE PERMIT"NO. INFO EH 13-241REV.WWI �� , S371 - EH 14-26 i�