87-3442 (2) - Laserfiche WebLink

Home Browse Search

�r 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 N 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �� Job Address City -Lot Size PM Owner's Name Address Phone Contractor LAddress C b License No.�APhone_ a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , PUMP INSTALLATION Ll SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:'SEPTIC-TANK-- —-----'SEWER-LiNESr- -^ -- —DISPOSAL=-FLD- --;-----PROP--LINE--_—_-- --- FOUNDATION ROP:•LINE-- -- - ---FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca - Dia. of-Wel!Excavation Dia. of Well Casing L) Domestic/Private - ❑ Gravel Packr ❑ Tracy Type of Casing ., Specifications a '.F1 Public ❑ Other i Cl Delta Depth of Grout Seal Type of Grout is 1 I Irrigation _.-Approx. Depth l I Eastern � Surface Seal'Installed by Repair Work'Done ❑ Type of Pump- H.P. State Work Done i Weil Destruction ❑ Well Diameter Sealing Material (top 50'11 l t Depth Filler Material IBelow 501 V� TYPE OF SEPTIC WORK: NEW INSTALLATION.01-.-REPAIR/ADDITION Z_-01E9TRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.), Installation will serve: Residence Ll_ Commercial Other i .Number of living units: __A• Number of bedrooms Character of soil to a depth of-3 feet: Water table depth SEPTIC TANK Type/Mfg 4 Capacity j at�� No. Compartments PKG. TREATMENT PLT. ❑ I _ Method of Disposal Distance to nearest: Well �7 Foundation Property Line LEACHING LINE Q_—ND. & Length of lines_ _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i�—rSep _ Size 3 (n Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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, f 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 cert he 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 o alifornia.11 _ The applicant cit for I re' 'red i ctiq s. Co le a drawing on rev rse side. Signe Title: Date: R DEPARTMENT USE ONLY Application Accepted by / Date Area f Pit or Grout Inspection byDate L Final Inspection by Date rr Additional Comments: Vf ❑ 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 t FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. f EH13-241REV.1i851 EH 14-26 11VVV V L a\ ID