91-0057 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Wealth 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. q' y� AVE— Job Address ^_2/ / 3 YAt L- >p`�Y f City Lot Size�/ PM f 747,7 Owner's Name- AddressPhone . . . - Contractor Address License N Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D r 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 PRO13LEM AREA CONSTRUCTION SPECIFICATIONS n ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ezcavaiion Dia. of Well Casing [�I✓� ❑ Domestic/Private ❑ Gravel Pack a ❑ Tracy -- - -Type-of Casing 4- Specifications f .� 1'1 Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation __.Approx. Depth l I Eastern Surface Seal Installed by p � Repair Work Done ❑ Type of Pump H.P, State Work Done 0 Well Destruction D Well Diameter ` Sealing Material (top 501 Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION iNo septic system permitted if public sewer is i r vailable within 200 feet.) Installation will serve: Residence�' Commercial— Other Number of living units: 2 Number of bedrooms CJ Character of soil to a depth of 3 feet: AtA. Water table depth SEPTIC TANK V,Type/Mfg Capacity' No, Compartments PKG. TREATMENT PLT. ❑ 00, `• Method of Disposal Distance to nearest: Well Foundation t— Property Line oW LEACHING LINE ❑ No. & Length of lines Total length/size ' 1 FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth I Size Number E SUMPS Cl Distance to nearest: Well Foundation... _ _ ___ P.roperty,,Line i ei 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. 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 mannef as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject toworkman's compensa- tion laws of California." The applicant must call for all required insoi;c`tTo-as, Complete rawing on reverse side. - ► i Signed X Title: Date: FOR DEPARTMENT USE ONLY ? Application Accepted by ,Date �� Area Pit or Grout Inspection by Date Final Inspection by K S P - Data Z-A Additional Comments: l f r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 1 FEE INFO AMOUNT DUE AMOUNT REMITTED CK f CASH RECEIVED BY DATE PERMIT*NO. - _. .. r EH 13-24(REV.t i K sl EH 14-26 �C r 1 t ) I 4 Ia �R ` F .1