87-1798 - Laserfiche WebLink

Home Browse Search

k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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 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. CityiZa4L Lot Size at Job Address PM POP- �15 29rS" Address Phone Owner's Name C [� Contractor Address & t License No J Phone J TYPE OF WELL/P P:. ,NEW,WELLa❑_,.,,,,,,,WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES V DISPOSAL FLD. PROP,1#E� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT (CATIONS D Industrial ❑ Open Bottom ❑ Manteca all Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Tra Type of Casing Specifications ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout _. �. 1 1 Irrigation x. Depth I I Eastern Surface Seal Installed by - !" Repair Work Done ype of Pump H.P. State Work Done _ V Well Destr ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK:-NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION/[l (No septic system permitted if public sewer is available within 200 feet.? Installation will serve: Residence_ `Commercial_ Other S Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANKi ❑ Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT- ❑ -�,,..,,,,,,.y , Method of Disposal Distance to nearest: Well Foundation Property Line 1 . LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS i ❑ 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 I rules and regulations of the San Joaquin Local Health District,— ___ l 1, 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."t 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 The applicant must for uired i tions. C late drawing on reverse side. Signed X F Title: Date: — R DEPARTMENT USE ONLY I I Date Area 03 Application Accepted by Pit or Grout Inspection by Date Final Inspection by Additional Comments. l-7�7 y-r,.s.es3�.. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tray 835- 5 Applicant- iReturn all.copies tor.Environmentel Health Permit/Services•1601-E. Hazelton Ave4—P.O:4Box 2009;StkrrCA 95201 g _FE E AMOUNT DUE AMOUNT REMITTED CK CASH- RECEIVED BY DATE PERMIT NO. � iEH13,2/(REV.1/H5) (NFD C1'�f ��, � r6 ►�J .. Y, EH 14-26