87-3404 - 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 Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. qe) N *h CCS &fir' Lot Size H® � PM Joh Address '7L� #C1ity �t�� r� Owner's NameulkiAddress !- `o N. `"`^"'' � Phone F ..� (� f1 n ,f_ 9' Contraeto �J c L Address t`� e 7'1C C"F7�^ License IVot ��[7�'SI� Phone75 �cr TYPE OF-'.,WELL-1 PUMP:- NEW WELL ❑ WELL REPLACEMENT,❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 11 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l h I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private - ❑ Gravel Pack ❑ Tracy- Type of Casing" s Specifications 71 Public F1 Other IJ Delta Depth of.-Grout Seal- - -: Type of Grout I I Irrigation Approx. Depth I I Eastern Surface fSeal 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 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADD( ION le DESTRUCTION l 1 (No septic system permitted if public sewer.is available within 200 feet.) 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 0 + 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 � w SEEPAGE-PITS I1,�Depth S ' Size Number � —e SUMPS -_❑ Distance to nearest: Well ICja Foundation [O Property Line DISPOSAL PONDS ❑ f r I hereby certify that l have prepared this appficatian-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 District7e' _ 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 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 fallowing: "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 applicantust call to II r uired inspections. Complete drawing on reverse side. Signed X Title: `0. P" Date: qlg S 7 FOR EPARTMENT USE ONLY Application Accepted by Date _-!�Jf7— Area it r Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ 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 RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24 IFIEV.r i H b) EH 14.26 6 / V