87-3368 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 F PERMIT EXPIRES 1YEAR 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 Sari Local Health District. Joaquin Jab Address City Lot Size Ply Owner's Name ZAddress Phone Contractor + Address License N (9' 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 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack [D Tracy Type of Casing Specifications I i Public Cl Other Ll Delta Depth of Grout Seal Irrigation Type of Grout _ 9 ---Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth i Filler Material (Below 50') vV TYPE OF SEPTIC WORK: NEW INSTALLATION 1:7 REPAIR'/ADDITION I I DESTRUCTI I } (No septic system permitted it public sewer is / f available within 200 feet.) Installation will serve: Residence Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:'r / --__ - Water table depth SEPTIC TANK ❑ Typi f Capacity-PKG. TREATMENT PLT. ❑ t y No. Compartments IMethod of Disposal Distance to nearest: Well Foundation-'Property Line LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ❑ Distance to:'nearest: Well Foundation%, Property Line tl SEEPAGE PITS I I Depth -4J--M!-� -^ -Size"�"�'�"� �~ Number SUMPS ❑ Distance to�nearesi: Well Foundation DISPOSAL PONDS Property Line 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 license g is 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 c ma net s to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following '9 f t at the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of Califor " The applicant must all ns�ctions. Complete drawing on vers Signed X , Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ` Area Pit or Grout Inspec by DateFinal Inspection by �f Date Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 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 INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV,r i n 57 � .V© �j% CX�7 erg.r/� EH 14-28 r ~�� r� / V / 33