87-4003 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 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) 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 welt/pump and the Rules and Regulations of the San Joaquin Local Health District. r � - f rGity Lot Size Job Addres �rJ Owner's Name Address ' Phone Contractoddress License No.10 TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT El ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LlOTHER 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ 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 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll❑ REPAIR/ADDITION DESTRUCTION allo septic system m se ALpermitted if public wer is Installation will serve: Residence t! Commercial_ Other Number of living units:1— Number of bedrooms ti Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ElTypelMfg � '- Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of DisposaV {� F Distance to nearest y Well Foundation % — Property Line `1 LEACHING LINE No. & Length of lines Total length/size FILTER BED 'I'❑- Distance to nearest: Well Foundation Property Line I - SEEPAGE PITS ❑ Depth Size Z �gqN4mber SUMP ❑ Distance to nearest: Wei ` Foundation J__LJ[�- Property Line %TVF0SAL ❑ 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 applicant ust c for all re ere "nspections. Comp drawing otw side. Signed Title: Date: FOR DEPARTMENT USE ONLY Applic tion Accepted by � Date � � Area �1 d DateP, iF - ut Ins ction by rD.t.,"S-1— Final Inspection b Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 8354385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } Y 'AVN CK a FEE AMOUNT DUE AMOUNT REMITTED A RECEIVED BY DATE PERMIT''NO. GASH + EH 13-24(REV.1/551 INFO -70 rb � EH 1428 �..