87-2612 - Laserfiche WebLink

Home Browse Search

4C;. APPLICATION FOR PERMIT I` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) :f 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. Jab Address e �. City / "!' Lot Size , PM Owner's Name Address Phone Contractor < Address License No 7 Phoney TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP, 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`l Public ❑ Other C1 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 (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION (.I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence"' Commercial____ Other �j / Number of living units: Number of bedrooms I a 6S�[ 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: Well Foundation Property Line l LEACHING LINE ❑ No. & Length of lines _ _ _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .r. SEEPAGE PITS I I Depth Size Number SUMPS El 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 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 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 applica us ca I or all required inspections. Complete drawing on reverse side. e&J r Signed Title: 2J�- � Date: — FOR DEPARTMENT USE ONLY Application Accepted by �1'z t�� Date Area � Pit or Grout Inspection by Date Final Inspection by les Date �-1by �, ___ �n Additional Comments: ___._ [ '�`"""'r 'r `� C S41 od 1411 f4 tk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Aacy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH j +,EH13-24iREV.-t/N51 � ' .3.3s--00J1p].d0 � r� �� '� • •��L� EH 14-26