87-3444 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I .i 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 f 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1 City Zu Lot Size PM hyJ7Owner's Name Address Phone� / Contracto Address se No. Phone a TYPE OF WELL/PUMP: NEW 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 I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca .f Dia-of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications I'1 Public ❑ Other ❑ Delta 9 Depth of Grout,Seal ^' Type of Grout I I Irrigation _____Approx. Depth I 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 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALL TION i-1 REPAIR/ADDITION I I DESTRUCTION I I {No septic system permitted if public sewer is a available within 200 feet.) Installation will serve: Residence Commercial--- Number of living units: 4— Number of be ooms � 41 Character of soil to a depth of 3 feet: Water table depth 00 SEPTIC TANK ' ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ f r ` Method o/f Dis osal Distance to nearest: Well ,Foundation� Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation �O Property Li 1 c _ SEEPAGE PITS I I Depth Size Number_ Cl 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 r_ 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 1 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 or squired i cti ns. Comp) a dr ing on re er side. Signed Title: Date: FqR DEPARTMENT USE ONLY Application Accepted by 0IR Date Area f Pit or Grout Inspection by Date Final Inspection by V. Date r Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT-NO. EH 13-24/REV.1?jib) EH 14-26 ! ra 1