87-3137 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTQ 1601 E. HAZELTON 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. ,t p y Job Address �7 '/ t, __ City S F �� Lot Size PM Owner's Name pN-AF,P SfO]� Address Phone Contractor%I IN)T� 1( 1.1 Address License No. Phone 9S 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'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _.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 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION ( I DESTRUCTION septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 4—,X/Ommercial____ Other y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity r 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 1 ) Depth Size Number SUMPS 0 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. 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, I shall not loy any person in su manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifi a following: "I ce 'fy that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws o alifo ia." The applicant u all for all r uire ns i ns. mpl _ drawing on verse si Q Sig ills: Date: (� r ao r �� FOR DEPARTMENT USE ONLY Application Accepted by � _ Daterea Pit or Grout Inspection by Date Final Inspection by LDate h r . Additional Comments: ❑ Stk 466-6781 ❑ Lodi A-3621 ❑ Manteca 823-7104 ElTracy 835-6385 v Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box M. Stk., CA 85291 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ♦ EH 1329 IREV.r/x 51S `_ 4isb4sq _ IEH 11-28 A -] 1