86-1210 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �j SAN JOAO,UIN'LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 5 Telephone (209) 466-6781 g 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. 1662 for well/ and the Rules and Regulations of the San Joaquin Local Health District. ' 1 Job Address --633' ddress City Lot Size PM Owner's Name � - - Address Phone .-J < s Contractor Address License No. Phone TYPE OF WELL/?UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J 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 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout EI-Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by c Repair Work Done ❑ Type of Pump H.P. State Work Done W Weil Destruction ❑ Well Diameter Sealing Material (top 501 W Depth Filter Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (Nosepti system m permitted mittepublic sewer is availabInstallation will serve: Residence Commercial Others Number of living units: Number of bedrooms ' f Water table depth Character of soil to a depth of 3 feet: " k Capacity ' No. Compartments SEPTIC TANK X Type/Mfg ,r PKG. TREATMENT PLT. ❑ IVIe h d of Disposal Distance ty o nearest: Well Foundation Property Line II Y LEACHING.LINE f.` ❑ No. & Length of lines Total length/size FILTER BED y ,� ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS El Depth Size Number SUMPS ❑ Distance to nearest: Well 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. Homeowner 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 ust call for all required inspe tions. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY i Area Application Accepted by 1 Date , , Grout Inspection b ''- Date Final Inspection by y v "'^C Pit or G Pe y � Additional Comments: ❑ Stk- 466-6781 --❑-Lodi 369-3621 ❑ Manteca' 823-7104 .. ❑Traay 635 6385 Applicant- Return all copies to: EnvironmentaLHealth Permit/Services.1601,E. Hazelton Ave., P:O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. INFO ' - 3,S-n � 13(0 3 ►t+Q + EH 5324 IREV.1/a 5) { EH W26