87-3848 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Regulations of the San Joaquin Local Health District. '' Job Address wj City Lot Size /CA Owner's Name, 4TH. JD 15 LZZ/ Address Phone �r l6" � � ! License No `�5 3� Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ e PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ kA A� r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "�l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ❑ Open Bottom ❑ Manteca •Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public FI Other Cl Delta Depth of Grout Seal Type of Grout E I Irrigation -_..App(ox.-Depth l 1 Eastern - :-Sur4ace-Seal4nstalled by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 4 Depth Filler Material IBelow 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIRIADDITION f I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence commercial— Other 'Number of living units: _/_ Number of edrooms Character of soil to a depth of 3 feet: +7i��. ®..0• Water table depth F SEPTIC TANK ❑ T ype/K4fg�,1S w✓'C'<, dr Capacity No. Compartments PKG. TREATMENT FLT. ❑ _ _ Method of DispoPI Distance to nearest: Well/!296- Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines O ' Total length/size 420 FILTER BED ❑ 'Distance to nearest: Well MtQ- IFoundation� Property Line SEEPAGE PITS I 1 Depth Size Numbert �a SUMPS Distance to nearest: Well-4eird—i- Foundation Property Line " DISPOSAL PONDS ❑ f I hereby certify that I have prepared this application and that the work will be done in accordance Jith San JoaquirU 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 I erfotmance of the work for which this permit is issued, i shall not employ any person in such manner as� become subject to workman's compensation E ws of Califofftia." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this perm is issued, I sAali employ persdns subject to workman's compensa- tion laws of California." r r t The applicant call for require inspections. Complete drawing on reverse side., .. Signed X Title: Date: O , i1 i F E RTMENT USA LY j _ Application Accepted by _,4ml4 Date t �" Area Pit or Grout Inspection by Date Final Inspection by ' Date 1Additional Comments: -^ z• _ '❑ Stk 466-6781" ❑ Lodi 369-3621, ❑ Manteca 823-7104 s❑ Tracy *$35-6385 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 t EH 13-24(REV.1/n 5) /'/C,LA ) jg EH 14-2e /P V