87-3704 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin ; Local Health District. Job Address j i{ ft/cq City lot Size Owner's Name`f5 ��u�""�S �'x �`�" Address ��' ��'x X60 �� Gz� Phone ./ .7 .S/�'A.w�'�►/S Com!/lv� Contractor flGrci�tr ��h." Address 3z /zi�H/�� ,e � L ci ense No. Phone 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CiJNSTRUCTION SPECIFICATIONS LJIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Xaa} Dia. of Well Casing $�96ci Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications / t`l Public 00ther ❑ Delta Depth of Grout Seal ZO Ty e/of Grout �f""'" _. ✓ I 1 Irrigation Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dene Well Destruction ❑ Well Diameter Sealing Material )top 501 "x" '� Q Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW iNSTALLATION4W REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resid nce Commerciale Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �[ PKG. TREATMENT PLT. ❑ --"" Method of Disposal Distance to nearest: Well Foundation Property Line nn LEACHING LINE ❑ No. & Length of lines Total length/size y' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well foundation Property Line f DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. �l �c 7 C7lro Go$/�t �� cS Signed X f� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by 5 Data Area �], Pit or Grout Inspection by Date Final Inspection by tr Date y Additional Comments: E1YLlT- L�� © Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO r EH13-24 TREY,riwsi 3 EH 1928 t