87-1077 - Laserfiche WebLink

Home Browse Search

APPLICATION.FOR PERMIT W. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,,STOCKTON, CA Telephone (209) 466-6781 # PERMIT EXPIRES i 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 deseiibed.'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 Districts : C { Job Address - r,GV*'- A t ��.�CL� S' �t_ .city T �ot Size C Sal 5C7 PM Owner's Name -' Address a :Rhone+ " Contractor Address License No. Phone TYPE OF WELL/PUMP:—t)--N EW WELL❑""'"'"" —WELL REPL-A•CEMENT 6 -^- �DESTRUN_-CTIO ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (y INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx.,Depth ❑ Eastern ...-Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ G Well Destruction ❑ Well Diameter Sealing Material atop 501 } Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR'/ADDITION-0 DESTRUCTION ❑,(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-1 Water table depth SEPTIC TANK ❑ type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines r" Total length/size FILTER 'BED ❑ Distance to nearest: Well Foundation 1 Property Line a SEEPAGE PITS ❑ Depth Size- Number SUMPS ❑ Distance to nearest:i •'Well Foundation Property tine DISPOSAL PONDS N❑ t"ys�, r 1,4 I hereby certify that I have prepared thisapplication 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 licerised agent's signature certifies the fallowing: "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 toIbecome 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 must c 11 for all quir nsfjactions. Complete drawing on reverse side. ,/—Signed Title:s Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Data U Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 1 l ,{ f ❑ Stk 456-6781 ❑ Lodi 369- .1 ❑ Manteca 823-7104 . ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CRECEIVED BY DATE PERMIT'NO. + EH 13-24(AEv.liNsl _ �r—..`vt� .. �OC� ��'ASH i l �`rl•-' ��•-•-� -1 �O v rEH 14-25