87-2888 - 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 TYEAR 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 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f Job Address q 17 Cit PM S '�I Owner's a 1 Phone _)37Contractor ddress eo License hto. Phone TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION B� SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE V\` FOUNDATION :AGRICULTURE WELL OTHER WELL PITS/SUMPS � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Diafof Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1--1 Public 1-1 Other n Delta Depth of Gro$t Seal Type of Grout _ 1 Irrigation Approx. Depth l I stem r SurraFe al'fnstalled by Repair Work Done e' Type of Pump P It".P. _L_!Y State Work Done Well Destruction ❑ Well Diameter -Sealing Material (top 50') Depth -�Filler,Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION t I DESTRUCTION I I INo septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence_ Commercial�/fOther 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well - Foundation Property Line SEEPAGE PITS 11 Depth SizeA'.- Number t. � 4 a SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS `'` - - I hereby certify t I have prepare this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and re ations of the San Joa urn Local Health District. i r '- Home ow r or licensed agent's sign tura certifies the f owing: "I certify that in the performance of the work for which this permit is issued, I shall not employ a person in such manner a t come subj to rkm s ompens � aws of California."Contractor's hiring or sub-contracting signature certifies a following:"I certify th r t pert ma f e w fo i is p ' is issued, I shall employ persons subject to workman's compensa- tion law of California." The app'cant must a uired in s Ingo rev rs rde Signed X i e. ;- bate: FOR DE `] PARTMENT USE ONLY Application Accepted by ' 4Date < -3d Area Pit or Grout Inspection by Date Final Inspection by 2d Z5A1 Date Z&;10- Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13-24IRE V-r/H5) EH 14-28 � �'�