87-3708 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 1. 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. y Job Address City Lot Size PM Owner's Name Address Phone Contract r ' Address L 2�2� Phone License No. E TYPE OF;WELL/ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION EI t-: — --" PUMP-STALtDkTION-'❑L_7 SYSTEM-REPAIR ❑ OTHER L7 !' DISTANCE TO RES ,; . _ Y C TANK SEWER LINES DISPOSAL FLD. PROP. LINE " OUNDATh_ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE �_TYPE-(SrWELL �PROBL A CONSTRUCTION SPECIFICATIONS ❑ Industria! ` 6.1___ L Open Bottom ❑ Mantec_a..,� *,_ Well Excavation Dia. of Well Casing 11-Domestic/Private ❑ Gravel Pack ❑ Tracy .*'' Type of Casio Specifications 1`1 Public Ll Other CI Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _._Approx.' Depth I 1 Eastern Surface Seal Installed by Repair Work Done {j Type of Pump H,P. State Work Done_ ,�. Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION W REPAIR/ADDITION I.1 DESTRUCTION I 1 (No septic system permitted if public sewer is i } / h, available within 200 feet.I S ; Installation will serve: Residence_ Commercial Othe 110.(�1C11 Number of living units: Number of Odrooms I c. I Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK {H'/Type/Mfg r Capacity_1.2_ o No. Compartments PKG. TREATMENT PLT. ❑ i f f Method of Disposal Distance to nearest: Well Foundation C) Property-Line LEACHING LINE ❑ Nd- & Length of lines Total length/size '- i FILTER BED_ : w ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to. nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ �-� 4� n { 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"o rules and regulations of the San Joaquin Local Health District. Home owner r licensed agent's signature cetifi�the following:- I-certify that in the performance of the work for which this permit is issued, I shall not ' employ any person in su tt�manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:-'I-ce Ify that in ttie performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California.'� w: The applicant u call for-all a ire 'nspectio s Complete drawing on reverse Vid.. Signed X: Title: _ Date: . .. Application Accepted by FOR EPARTMENT USE ONLY ` .rDate � "'' Area fi ., Pit or Grout Iris ��' � -^ --^-- ,rye pectian•by Final Inspection by © A Date ( wt Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 e Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTECASE! D CK INFO RECEIVED BY DATE PERMIT'NO. f + EH 14-241REV.v/H5l �Q EH 1428 7b*�� _ iZ7~37a% /