87-823 - Laserfiche WebLink

Home Browse Search

Y. APPLICATION FOR PERMIT 14" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,. STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F (Complete in Triplicate) rI 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. t Job Address _ ` City of Size f if PM Owner's NameY90Address T 3 " J�—^ Phone 7(-' I ontractor Address License No. L.<Phon TYP WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of aUon Dia. of Well Casing i I ❑ Domestic/Private El Gravel Pack _ ❑ Tracy r Type of Casing Specifications ❑ Public ❑ Oitier ❑ Delta Depth of Grout Seal r e of Grout ` ❑ Irrigation --Approx. Depth ❑ Eastern k Surface Seal Installed by Repair Work Done ❑ Type of Pump s H.P- State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 1 Depth, Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic.system permitted if public sewer is available within 200 feet.) Nvek Installation will serve: Residence_ Commercial Other r 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 PLT. ❑ r j Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 applicant must call for all r uired i spections. Complete drawing on reverse side. Signed Title: Date: F RWE T USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date /� _(F{inal Inspection by Date ? Additional Comments: u y OU5 e -t -+ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CAS K Fi RECEIVED BY DAT//E�� " PERMIT'NO. ; + EH 1428 3-24(REV.5/N 5) • I_ �—/947 1 D 77- EH 1 `�"� O /