87-652 - Laserfiche WebLink

Home Browse Search

F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 5 _ 4 1601 E. HAZELTON AVE., STOCKTON, CA h Telephone (209) 466-6781 L �p f10 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a P �° (Complete in Triplicate) t 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. r„ Job Address L �__(� As'% �� r1� A�/ City STac ;� Lot Size 76 , PM i Owner's Name Address Q F Phone d � a Contractor Address License No. 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 AGRICULTUREyV1lELL OTHER•WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ¢ ❑ Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approxii Depth L7 Eastern Surface Seal Installed by i Repair Work,Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 4 Depth ,I Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUC ON ( o septic system permitted if public 'sewer is ailabIL- within"200-fe-dt.) I Installation will serve: Residence Commercial_ Otherrv� -- Number of living units: Number of bedrooms t ` Character of soil to a depth of feet: v Water table depth SEPTIC TANK ElType/Mfg/ Capacity No. Compartments LlPKG. TREATMENT PLT. Method of Disposal s It Distance`to nearest: Well Foundation Property Line 3 L LEACHING LINE ❑ No. & Lerigth of lines Total length/size 3 FILTER BED ❑ Distance:to nearest: Well Foundation Property Line ii 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 es and regulations of the San Joaquin Local Health District.' 3 9 q ct i Home owner or licensed agent's signature certifies the following: "I certify that in the`pertormanoe 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 df'California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this piJiNif-i0ssued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all require inspections, Complete drawing on reverse side. Signed x-� _ Title: Date: �_Fr 7 r� FOR DEPARTMENT USE ONLY � I Application Accepted by Date. �L rea (:3 Pit or Grout Inspectio y Date Final Inspection by Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621. El Manteca 8,2 M3-7104 ❑ Tracy -835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE '�tt AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH1 -241REV.1/e5Y EH 144-26