87-3405 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZEL T Ofd AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. y� Job Address 6 V City "/P—)Lot Size PM Owner's Name ddress //—� Phone Contractor 4&&6�x4l Address c5 3Co ,E- License Id lJl� < d .Pho4�2 S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK 3 SEWER LINES DISPOSA PROP. LINE FOUNDATION AGRICULTURE WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing '\ ❑ Domestic I Private ❑ Gravel Packacy Type of Casing Specifications f'7 Public r Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation �, x. Depth I I Eastern Surface Saar Installed by C Repair Work Done ❑ pe of Pump H.P. State Work Done Well Destructi ❑ Well Diameter Sealing Material Stop 50'1 (rt Depth Filler Material (Below 501 – v1 TYPE OF SEPTIC WORK: NEW INSTALLATION {-1 REPAIR/ADDITION t I DESTRUCTION No septic system permitted if public sewer is available within 200 feet.) Installation 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 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 11 Depth Size Number SUMPS 0 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 that in the performance of the work for which this permit is issued, l 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,l shall employ persons subject to workman's compensa- tion laws of California." The applicannnust call for all required inspections. Complete drawing on revrsa side. Signed Title: Date: FOR DEPARTMENT USE ONLY q /; Application Accepted b Date Area - 1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca EE23 7104 ❑ Tracy 5-6385 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 CA H RECEIVED BY DATE PERMIT'NO. )NFO + EH 13-24 41REV.1/H 51 �� EH 14-29