87-4233 - 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 T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he,eby 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. Jab Address City Lot Size PM Owner's Name Address Pho DC7 Contractor Address License No Pho� ' TYPE OF WELL/PUMP: NEW WELL F1 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. FOUNDATION AGRICULTURE WELL O ELL s PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONST ON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tia Type of Casing Specifications F] Public C1 Other hDelta Depth of Grout Seal Type of Grout f I Irrigation __Appro epth, I I Eastern Surface Seal Installed by ' Repair Work Done ❑ T Pump at ' " r H.P. State Work Done_ Well Destruction Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION 1 l DESTRUCTIO (No septic system permitted if public sewer is " -available within 200 feet.) Installation will serve: Residence Commercial— 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. D Method of Disposal t� t ( � t Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length df lines '• Total length/size FILTER BED , ❑ Distance to nearest: Well Foundation Property Line 4_ # J _ t SEEPAGE PITS I ] Depth Size _F" Number I SUMPS j L-1 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. I 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 followinb: "I certify that in the performance of the work for which this permit is issued,1 shaillemploy persons subject to'workman's compensa- tion laws of California." - w The applica must call for all require "nspectio s. Complete drawing on r"se side. 01 Signed " ' Titla� Date: FOR DEPARTMENT USE ONLY Q� " Application Accepted by Date 2 O Area Pit or Grout Inspection by Date Final Inspection by Date a(I" 5A_ itional Comments: o if &Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO er13-24 rRev., x s, 3S7 EH 1028 S. t—H L