87-3030 - 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 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 Joa Local Health District. ' Job Address 'C) City 5rot Size PM l Owner's Name ddress Phon Contractor Address .License No. - - .Phone TYPE OF WELL/PUMP: tNEW WELL.El _. ,,_WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INS _ N ❑ SYSTEM REPAIR ❑ OTHER ❑ �- "" DISTANCE TO NEA EPTIC TANK R--LINES DISPOSAL,FLD- PROP. LINE A FOUNDATION AGRICULTURE WELD-�rO7�WELL PITS/SUMPS E INTENDED USE y TYPE OF,WELL PROBLEM AREA�CONS -RTUICTION S�PECIFI'C-'CATIONS - kI ❑❑ Industrial 'a ❑ Open Bottom ❑ Manteca - Ria- of Well Excavation ia. of-Well-Casing k lt�l-Domestic/Private ❑ Gravel Pack L: Tracy Type of Casing Speci 1 ons �~ _ i ❑ Public ❑ Q.Lb f r Delta Depth of Grout Seal Type of Grout----- ~ I Irrigation __Apprdx. Depth I I Eastern Surface Seal Installed by ~� Repair W one ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION LI DESTRUCTION I (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 FLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS 1 1. Depth k Size Number ` SUMPS L❑ Distance to nearest: Well Foundation Property Line DISPOSALPONDS...... L. - .r.4- . . -- --.r - 1w_: - I hereby certify that I have prepared this application and that the work will-156-clone-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 follow--rng:;'I certify that in the performance ofthe --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." Contractors 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 to workman's compensa- tion laws of California." III The applicant flust all r re aired inspections. Co p! t drawing on reverse side. � -.. Sign d Title: . Date: [ FOR DEPARTMENT USE ONLY p�_1 Application Accepted by ` I�,, ' -V1 0 Date rJr l Area Pit or Grout Inspection by Date Final Inspection by 44LW4V Date 2h,31t7 Additional CommentsA/� _-- _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Y Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DDE' AMOUNT REMITTED CASH RECEIVED BY DATE f PERMIT'NO. + EH 13-24(REV.t/K 5) EH-14-28 I