87-2026 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE.,,STOCKTON, CA Telephone (209) 466-5781 ' PERMIT EXPIRES .1 YEAR FROM DATE ISSUED ir..� (Completeiin 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 Reguiations of the San Joaquin Local Health District. —-' .i .r- .a , «o - Job Address _per / PSL _ City Lqot Size. r.L Owner's Name ddress I'Phone 74 Contractor ��le Address ^� 40 icense 6#i. TYPE OF WELL/PUMP: NEW WELL A— WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ZJ� -SYSTEM REPAIR ❑ .1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK --.7_....._ SEWER LINES DISPOSAL FL/D/, PROP. LINE FOUNDATION 3 p AGRICULTURE WELL - -OTHER WELL PITS/SUMPS _ !, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS i ❑ Industrial Open Bottom ❑ Manteca Dia. of Well-Excavafion P Dia. of Well Casing ff W" oomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing, . � r _ Specifications dl C ❑ Public ❑ Other ❑ Delta Z- Depth of Grout Sear �f a�-ff Type of ut ❑ Irrigation --Approx. Dept ❑ Eastern 5uAce-Seal Installed-h 1 Repair Work Done ❑ Type of Pump t H.P. � IState iNofk'�Done Well Destruction ElWell Diameter Sealing Material (tbla'50') """""' Depth Filler Material (Below 501 01 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (fila septic-system-permitted-if-public sew er*iS-� rh/ �.. .� available within 200 feet.) ;. •i Installation will serve: Residence Commercial Other S1a Number of living units: Number of bedrooms # ` 0 .y Character of soil to a depth of 3 feet: Water table depth 0 SEPTIC TANK ❑ Type/Mfg,__ ! Capacity r No. Compartments PKG. TREATMENT PLT. ❑ i f Method of Disposal tf 3. Distance t n H o Barest: Well ,Foundation Property rt Line LEACHING LINE El No. & Lerigth f`lines '"''_ _ i _ Total length/size FILTER BED ❑ Distance to nearest:,* � WFoundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: * Well Foundation Property L•ihb DISPOSAL PONDS ❑ 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 v[ 4r, 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 I employ any person in such manner as to ibecome subject to workman's compensation laws of California-"Contractor's hiring-or-sutrcontracting 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." .1 d The applicant must call for all required inspectio S. mplete drawing on reverse side. I Signed X rc Title:' Date: 1 o FOR DEPARTMENT USE ONLY Application Accepted by Date Area ' Pit or Grout Inspection b Date Final Inspection by Date t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 k Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'N1O.t * EH 13-24 IREV.1/H 51 EH 14-24