87-3499 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. FfAZELT ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k*A- IComplete 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. CS Job Address / O City Lot Size PM r Owner's Name1 E�LL A) h Address Phone (} p Contractor -b,50�7,50 ` C License No.tA 1109-IR Phone % a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT_0 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 PR06LEM A A CONS UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Ll Manteca 7Di . of Well Excavation Dia. of Well Casing ❑ Domes#ic/Private ❑ Gravel Pack ❑ Tracy _ of Casing Specifications M Public 1.1 Other ❑ Delta Depth of Grout Seal Type of Grout . I I Irrigation _..Approx. Depth I I t=aste 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 1 1 REPAIR/ADDITION l I DESTRUCTION eptic system permitted if public sewer is available within 200 feet.) tnstallation 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. TREATMENT PLT. ❑ Method of Disposal «j 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 l I Depth Size Number SUMPS i-1 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 mploy anyperson in such manner as to become subject-tworkman's compensation laws of California."Contractor's hiring or sub-contracting signature ea the following: ertify that in the performance of the k for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws California. The applicantMscaIlore requ a ins tion o late drawing reverse side, Signed Titl Date: 9- FOR EPA TMENT USE ONLY Application Accepted by Date [ �"� Area Y Pit or Grout Inspection by Data Final Inspection by �" r��-7� Date `---� Additional Comments: rrrai 6 L— ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant - Return all copies to: Environm ntal Health Permit/Servi s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. + EH1 -241REV.i/x51 2s ( � y /f /7 /�"��f� EW 144-26