87-421 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 9601 E. IiAZEL I 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 Local Health District. forwell/pump and the Rules and Regulations of the San Joaquin 4 Job Address ti � � x4 City Lot Size pM Owner's Name - p- - Address ��/ alGfirjl/ai Phone � Contractor Address p �f�l _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL =59!4 License Nophone REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El WELL REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESV DISPOSAL FLD. PROP. LINE ►V FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] industrial Id Open Bottom ❑ Manteca Dia. of Well Excavation ` F] Domestic/Private C1Gravel Pack f_1 Tracy Dia. of Well Casing Type of Casing Specifications ❑ Public ❑ Other ❑ Delta ' Depth of Grout Seal ; F1 Irrigation Type of Grout --Approx. Depth F3Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. T Well Destruction LJ Well Diameter State Work Done _ Sealing Material [tap 50') Y Depth i Filler Material (Below 50') �L TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITi. ION ❑ DESTRUCTION«_ (No septic system Permuted if public sewer Installation will serve: Residence J Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - r SEPTIC TANK iWater table depth PKG. TREATMENT PLT. I ❑❑ Type/Mfg _ Capacity No.Compartments Method of Disposal Distance tolnearest: Well Foundation r Property Line i LEACHING LINE _V'No. & Length of lines - FILTER BTotal lengthlsize BED Total to:nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size � Number i SUMPS a -❑ Distance to nearest: Well a 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 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."Contractor's 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." y Ei k The applicant mypt call for all required inspactions..Compiete drawing on re arse side. SignedPonAccepted e -C Title: �- Date: FOR DEPARTMENT USE ONLY r Applica by _ Date Area 0 . Pit or Grout Inspection b e Date Final Inspection by I Date Additional Comments: Air o I ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Monte 823-7104 ❑ Tracy 835 6385 moi` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 sof # i.. -I , FEE AMOUNT DUE AMOUNT REMITTED CK INFO { H RECEIVED BY DATE PEflMIVNO- + EH 13-24(REV.5/B 5) 1e'[ 3s_ Dd 5 e © r EH 1428 �� ;