87-13 - Laserfiche WebLink

Home Browse Search

f� r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL`HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' .. (Complete in-Triplicate]'t Application is hereby made to the San Joaquin Local Health District for a permit toconstructand/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. , Job Address t�L Crt, Lot Size PM ' Owner's Name Address _ ne �� -- Contractors P License No.�3?Cp2- o� 'o l Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 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•�CONSTRUCTI ON SPECfFICATIONS- . ❑ Industrial ❑ Open Bottom 5 Manteca Dia. of Well Excavation Dia. of Well Casing T omestic/Private ❑ Gr.vLl Pack ❑ Tracy Type of Casing Specifications j ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern i Surface Seal Installed by Repair Work Done ❑ Type of Pump.,, H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [t(jp 501 Depth Filler Material lBelow 50') r �> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITI�DESTRUCTION ❑ (No septic system permitted if public sewer is U available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms - t Character of soil to a depth of 3 feet: acitWater table depth SEPTIC TANK ElT Type/Mfg p" �x Yp g Capy No. Compartments PKG. TREATMENT PLT. ❑ �)k Method of Disposal Distance to nearest: Well 1 'Foundation Property Line LEACHING LINE ❑ No.•& Length of lines 9 Total�Iength/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 ❑ 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 pat in the performance-of the work for whichi`ttiis permit-is issued;I shall-not a__., employ any person in such manner as to become subject to workmans' .com ensation,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 mus all for ap-r9quired inspections. Complete drawing on reverse side. l Signed i Title:_)62111 Date: OR DEPARTMENT USE ONLY ` Application Accepte y Date a 8 Pit or Grout lnspecti by '" Date__ Final Inspection by Date 4 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED 8Y DATE PERMIT"NO. INFO CASH + EH 13-24 MEV.I/a 5) I' EH 14-26 - Q a 1/ ►J1� f e 1 .r