87-4320 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT-- SAN ERMITSAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T 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 wor rein escnbe ation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regula �A r an Joaquin Local Health District. Job Address WA17 � - City , t Size PM Owner's Name Address r Phone Contractor Address f�2&C nei7 OWLicense No. Phone TYPE OF WELL/PUMP: _��.. NEW WELL,LJ. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X1 SYSTEM REPAIR ❑ OTHER ❑ l 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 I .,,E] Industrial 0:Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing - Domestic/Private ❑i Gravel Pack ❑Tracy Type of Casing Specifications + ❑ Public Cl'Other. F] Delta Depth of Grout Seal Type of Grout I Irrigation 1 -Approx. Depth I ) Eastern Surface Seal Installed by x Repair Work Done ❑ Type of Pump H.H.P._ �' State Work Done II.I;S7- .0/_ Well Destruction © Well Diameter Sealing Material (top 501 LVp Depth Filler Material (Below 501 5 4 TYPE OF SEPTIC WORK: NEW INSTALLATION (,l REPAIR/ADDITION l I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200,feet.) F Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a dept hr of 3 feet: Water table depth j SEPTIC TANK ❑ i Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ~ I Distance to nearest: . Well Foundation Property Line d LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑II Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I: Depth Size Number SUMPS..., - = aCl Distance to,nearest::,,._Well _Eoundation. Property_Line DISPOSAL PONDS ❑it 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, 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa tion laws of California." 91, The applicant m fo all reitctions. Complete drawing on reverses. ,Q t Signed X_��f � 'f Title: //t 5 � - Date: -[� !I. FOR DEPARTMENT USE ONLY ,y -� Application Accepted by r Date 2 s Area Pit or Grout Inspection by Jy� Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 El Lodi 3621 ❑ Nfanteca 823-7104 ❑ Tracy 635-6365 Applicant -Return all copies!to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH III +.EH 13-24 1REV.I/R 5) Ld1,��3Sr E�0 �17 r7 ,7 �' EH 14-2e T ` /l �i