91-112 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 P PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;Complete in Triplicate) i I 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. j. C41t � / Job Address City f Lot Size PM P 19 3 7 Owner's Name Address L Phone / S I-16 Contractor Addressca�-�. sc License No. Phone TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [� ❑ Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation _,.Approx.`Depth t l Eastern Surface Seal Installed by l ]1 Repair Work Done ❑ Type of Pump H,P. State Work Done_ V Well Destruction ❑ Well Diameter Sealing Material Itop 50'i Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK; NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIO -INo septic system permitted if public sewer is f vailable within 200 feet.) Installation will serve: Residence—1 Commercial_' Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance b nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tp nearest: Well Foundation Property Line I i I SEEPAGE PITS I 1 Depth Size � Number I SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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'Eocal Health Diltrict. 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 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." I The applicant must mustt call for all requ ed inspections. Complete drawing on reverse side. Signed X 'Yq A Title: Date: i OR DEPARTMENT USE ONLY Application Accepted by Date Q Area Pit or Grout Inspection by Data Final Inspection by Date ! aC�no ' s`i pA" (_1Q&Xek� ,d V' Aix Additional Comments: _ iL �J1�- ❑ Stk 466-6781 ❑ Lodi 369-3 ❑ Manteca 823-7104 ❑ Trac 635-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I ) &rbne1- 1 1 Ply ! 01 FEE � Dw INFO AMOUNT DUE f AMOUNT REMI ED K RECEIVED BY DATE PERMIT'NO. r t +.EH 13-24 1REY.r A 51 EH 14-28 t, {i 1