87-2757 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 weli/pump and the Rules and Regulations of the San Joaquin Local Health District. IAS(-- Job Address City Lot Size ( AS( PM Owner's Name Address aoo 00 Phone Conlractw-4"a Address 1.2sU j GG r✓ License No.,76_,�,2-) Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done Cl Type of Pump W.P. _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION 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: r Number of bedrooms_,__ p Character of soil to a depth of 3 feet: Ld tv Water table depth SEPTIC TANK P�t-Type/Mfg(30 -/`1 Capacity_ Z6— _ No. Compartments Z PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well r Foundation�,-- Property Line lg�yr LEACHING LINE 04o. & Length of lin ✓f Total length/size If6 FILTER BED ❑ Distance to nearest: Well--�_ Foundation 5- Property Line tr SEEPAGE PITS l4/epth Size �2Number SUMPS Ll Distance to nearest: Well-+!S� Foundation_/ s , Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work willt one in accordance with San Joaquin county ordinances, state laws, arid rules and regulations of the San Joaquin Local Health District,. Home owner or licensed agent's signature certifies the following: "t 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." The applicant must call f r all quired inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY /Appplication Accepted by Date Area tc 1 PiY or Grout Inspection by pate Final Inspection by� Additional Comments: ❑ 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 31 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT ND. INFO CASH + EH 13-24(REV.F i H syS /(�� EH 14-26 �0 ?—I V