87-3102 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1VOu Telephone (209) 466-6781 X10 + PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) ? (? r 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. 9 d/ Lot Job Address / /" Cit v/�Lot Size PM Owner's Name � �� -��_,] Address Phon Contractor O Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ DISTANCE NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 Fl Public �I 171Other H Delta Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth ( 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 I:i REPAIR/ADDITION I I DESTRUCTION>s;l fNo 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. TREATIMENT PLT. ❑ ,�,_ Method of Disposal Distance to nearest: Well Foundation Property Line it LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BEDI, ❑ Distance to nearest: Well Foundation Property Line d1 SEEPAGE PITS l I Depth Size Number SUMPSi`. LlDistance 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 Local Health District. Home ownerl�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." Contractors 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 applicad must call for all re wired inspections. Complete drawing on reverse,side. iP _[ Signed X Title: 0/J)j P I Data: FOR REPARTMENT USE ONLY �I Application Accepted by ' Data �/ Area l0 SII° 2 2Li n Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY 4 DATE PERMITNO. a EH 13-24 iREV.i/nsl ��•U U ,�� i 0 �q EH 14-26 l� l k O