87-3080 - 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 (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. �Job Address,� � lb me -0 t,\ 1{ _ _ Cit t ize PM Owner's Namen n ut- ez' Address _ 1 Phone Contractor rAddress__ )2_ )_lam_ ar_+License No. Phone_ "1— l TYPE OF WELL/PUMP: NEW WELL 0 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 1-1 Public 1=1 Other H Delta Depth of Grout Seal Type of Grout I i Irrigation __Approx. Depth l 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 �(J Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is '+ available within 200 feet.I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f 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 SUMPS ❑ Distance to nearest: Well Foundation' Property Line DISPOSAL PONDS ❑ 1 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. I 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." Contractors 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." I F. , The applicant must call for alk required inspections. Complete drawing on reverse side. }L f� Signed X Title: y y Date: Z~j ]! FOP DEPARTMENT USE ONLY Application Accepted by ` Date "� Area Pit or Grout Inspection by _ Date FPpection Date WPM Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 s Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED �x FI RECEIVED BY / " DATE PERMIT NO. + EH 13-24{REV.ViH5r 7YrI) Q,17 �+�� EH 14"26 ��✓✓ V f7 I r