91-0868 - Laserfiche WebLink

Home Browse Search

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 j (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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. l � t�� S - (� City � Lot Size L'kCfC� PM Job Address Phone ir S Address Owner's Name Contractor r�- Address Z c` License No. 1q�_Phone — TYPE OF WELLIPUMP:. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISPOSAL FLD. PROP. LINE DISTANCE TO NEAR E57: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing F, Industrial El Open Bottom El Manteca Dia. of Well Excavation r,R Domestic/Private IA Gravel Pack 64 Tracy Type of Casing 4s0 Specifications I Public ❑ Other F1 Delta Depth of Grout Seal Nam i Type of Grout I I Irrigation alb Appfox. Depth I I Eastern Surface Seal Installed by IH P. State Work Done,— (j Repair Work Done ❑ Type of Pump 7' Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') o� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I availabe within 200 feetNo septic system .) if public sewer is Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms 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 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number t SUMPS Cl 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. ify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I cert 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 for all required inspections. Complete drawing on reverse side. Signed Title: ^ Date: !;I I FOR DEPARTMENT USE ONLY f Date Area • Application Accepted by F-- Date i Pit or Grout Inspection by C Date Final Inspection by i Additional Comments: eo- 0 Stk' 466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. zelton Ave., P.O. Box 2009, Stk., CA 95201 :FE CK ECEIVE Y DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTE CASH +.EH 1321 1REV.I/n 5) � - EH 14-28