87-4089 - Laserfiche WebLink

Home Browse Search

` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA # Telephone (209) 466-6781 1 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 for wewpump and the Rules and Regulations of the San Joaquin Local Health District. �� p PM CP Cit t e Job Address Adv Owner's Name E Gtr Address 3 Phone q 0 r dress 1�Sa License No3o lir? Phone1 7T' � r Contractorb�s` — TYPE OF WELLIPUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing ❑ Domestic/Private 13 Gravel Pack Cl Tracy Type of Casing specifications M Public ❑ Other 1 F Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 tj^ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ["I REPAIR I ADDITIONX DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: -Residencex Commercial Other Number of living units: _J. Number f bedro s Character of soil to a depth of 3 feet:' Water table depth SEPTIC TANK ❑ Type/Mfg apacity No. Compartments PKG. TREATMENT PLT. ❑ �` -' Method o1 Disposal #' J a / Foundation Property Line Distance to• - nearest: Well �Q a � LEACHING LINE �l No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well /DD_ Foundation Property Line 49 t i SEEPAGE PITS f I Depth i Size�L¢ (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. t 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 st ire ins ions. Complete drawing on reverse side. i Signed date: DEPARTMENT USE ONLY 'E Application Accepted by Date Area 1' Pit or Grout Inspection by jData Final Inspection by Date ? Additional Comments: L1Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca '1123-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I I ,1%., FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24(REV.1)N5) w EH 14-266z a