88-1494 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT E5 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 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 I� Local Health District. Job Address / Cif Lot Size PM Phone ]"Owner's Nam M rrr / License No. Phone TAddressontractor YPE 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications i M Public CT Other F1 Delta Depth of Grout Seal Type of Grout I I irrigation --Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Stop 5011 Depth Filler Material (Below 501 (� TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION LI DESTRUCTION (No septic system permitted if public sewer is �, - I.— __---- —--"" "" 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. ❑ Method of Disposal ► Distance to nearest: Weil Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS "Ll 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 i rules and regulations of the San Joaquin Local Health Diktrict. — - - — A 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 appli . nt ust tail fora r ui>£d inspections. Comple d wing on reverse side. Signed Date: 9 FOR DE RTMENT USE ONLY / Application Accepted by ATZ6enI Date "tel r Area ` Pit or Grout Inspection by Date Final Inspection by : ate Additional Comments '` C`` , '� ` "" I ❑ Stk 466-6781 ❑ Lodi 36.4-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1641 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'NO. INFO CASH r,EH 13.241 REV.1/n 5) EH 14-26 -