87-2721 - Laserfiche WebLink

Home Browse Search

r i !S APPLICATION FOR PERMIT �r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.; STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED + t m_ . ., (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address /��F� �LJ�� City' Lot Size PIM Owner's Na �— Address. Phone r *f Contractor Com , 1 Address License No. Phone TYPE_OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .PROP LINE; t r FOUNDATION AGRICULTURE WELL OT LL PITS/SUMPS'-' INTENDED USE TYPE OF WELL PROBLEM AREA CO ION SPECIFICATIONS yA ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casirig ❑ Domestic/Private ❑ Gravel Pack! racy Type of Casing _ Specifications Ll Public Ll Other C1 Delta Depth of Grout Seal Type of Grout ❑ Irrigation pprox. Depth Cl Eastern -::Surface Seal Installed'by Repair Work Do ❑ Type of Pump H.P. State Work Done . Well 0 ction ❑ Well Diameter : Sealing Material ftop 501 Depth Filler Material (Below 50.1 (� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is k available within'200 feet.) Installation will serve: Residence [Commercial_ Other 111 �- ---' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: : Water table depth o i SEPTIC TANK ❑ Type/Mfg CapacityNo. Compart ntsi A PKG. TREATMENT PLT. ❑ Method of Disposal Distance to:nearest: Well� � Foundation Property Line �- r LEACHING LINE ❑ Na. & Length of lines Total length/size =� FILTER BED ❑ Distance t`olnear est: WellFoundation yProperty Line I SEEPAGE PITS ❑ Depth ( Size +' Number SUMPS ❑ Distance to nearest: Well Foundation:14- Property Line DISPOSAL PONDS ❑ I . I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin countyordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1. 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 CaliforInJ6. ,-,Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whichthis permit is issued, 1 shall en`sploy_persons subject to workman's compensa- tion laws of California." T licant st call for all required inspections. omplete drawing on reverse side. ' ^7 ' Signed * Title: "'_ Date: f—ZG �. FOR DEPARTMENT U ONLY r Q Application Accepted byDate Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Logi 389-362T ❑ Manteca 823-7104 ❑ Tracy 8354XM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK V RECEIVED BY DATE PERMIT-NO.' + EH13.24fREV.i/a51U" EH 1428 J