87-3560 - 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 Ordirrc6NNo.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. c Job Address f + '11.c;. 4 City y &J Lot Size PM Owner's Name l address s+ Phone 9S 7--A 2 9 6 �r �T if Contractor Address 2aa_ / / _License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ .DESTRUCTION ❑ PUMP INSTALLATIONS 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 p ti LL�Ddfrestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other 1`7 Delta Depth of Grout Seal Type of Grout I I Irrigalion --Approx. Dept�r` +I�^Eastern Su ce Seal Installed by Repair Work Done */Type of Pump _..�.__ H.P. ___ State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50'1 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public-sewer is available within 200 feet.I L' Installation will serve: Residence_ Commercial_ Other Number of living units: a 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 i ❑ No. & Length of lines Total length/size FILTER BEDS Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that_I_have.�repared.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, 1 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 T certifies the following: "I certify in the performance-of The work for.which this permit is issued,"I shall employ parsons subject to workman's compensa- tion laws of California." The applicant ca11 r r i d ' pecti s Complete drawing on revers Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH /RECEIVED BY DATE PERMIT'NO. + EH 13-241Rf:V. /1t 51 EH 1426