87-1678 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �c" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED %J f {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 rt' 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' 'itrPilsJr , ` / r Job Address y �F City Lot Size A Z Y/00 PM -� Owner's Name~ �.� Xdr.. � J ,!�✓ ^[�7�sr '' Phone 4 Contractor ` =- d " dress--- A License-No: -�-- � OI---Phone TYPE:OF VV5LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL FLD� PROP. LINE FOUNDATION AGRICULTURE WELL O PITS/SUMPS F — INTENDED USE TYPE OF WELL PROBLEM AREA CONST N SPECIFICATIONS k• ❑ Industrial ❑ Open Bottom ❑ Manteca . of Well Excavation {! Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel.Pack.«. – ❑-Tracy —Type of£asing_j Specifications r ❑ Public ❑ Other f ❑ Depth of Grout Seal k-Type of Grout r ❑ Irrigation IApprox. Depth Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. E State Work Done Well Destruction ,. ❑ Well Dia er Sealing Material (top 50'1 f` Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ �UCTION ❑ (No septic system permitted if public sewer is a ilable ithin 200 feet.! lnsallation will serve: -Residence_ Commercial_ Other'{ l Number of bedrooms , !Number of living units: Character of soil to a depth of 3 feet Water table depth .SEPTIC TANK ❑ Type/Mfg Capacity- No. Compartments # PKG. TREATMENT PLT. ❑ ! Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines _1 Total length/size..I FILTER BED ❑ Distance to nearest: Well Foundation Property Line I I 4 SEEPAtGE PITS ❑ Depth � Size Number SUMPS ❑ Distance�to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ I i 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. i 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: "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.,' I t The a plica st call fg6 all requLred 'inspections. Complete drawing on reverse side. J ' Signed Title. � r Date. FOR PARTMENT USE ONLY 3 t ! c:71 Application Accepted by Date_ Area Pit oriGrout Inspection by " Date Final Inspection by t Date Addit anal Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy _835-6385 _. Applicant- Return all copies to:_Environmental_Health Permit/.Services-1001-E._Hazelton Ave.,.P.O. Box 2009,.Stk., CA 95201- FEE INFO AMOUNTn DUE: AMOUNT REMITTED CASCK*H w� RECEIVED BY DATE PERMII-VNO + EH1 3.241REV.1/8 5t EH 14-28