87-286 - 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address :D oft/, y 's�i� City F2 Lot Size PM Owner's Name .4 C'.i'4SD�Address w �G'" Phone Contractor h+ Address_ _ "�`��- / ITC License No. Phone 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 ❑ Public ❑ Oth6r ❑ Delta - Depth'of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other a Number of living units: Number of bedroopp Character of soil to a depth of 3 feet: Water table depth n SEPTIC TANK ❑ Type/Mfg 414" Capacity No. Compartments PKG. TREATMENT PLT. ❑ '] �`1 Method of Disposal Distance to nearest: Well Foundation 1 J� Property Line 10 F 7- LEACHING LINE No. & Length of lines Total length/size 0 F ' FILTERED Distance to nearest: Well 2_6_F`Foundation J' �r Property Line /Of� SEEPAGE PITS ❑ Depth Size Number ` SUMPS * i❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS k ❑ `* 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 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." The applicant must call for al qui- inspecti ns. Complete drawing on reverse side. r� Signed XA Title: Date: FOR DEPARTMENT USE ONLY )G Application Accepted by Date �! / �� / Area (/ Pit or Grout Inspection by Date Final Inspection by1L�G � Date 07 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36.21 antece 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE1 )NFO AMOUNT DUE. AMOUNT REMITTED CASH , RECEIVED BY DATE PERMIT NO. + EH 13-2A IREV.r/85) _ EH W%