87-2136 - Laserfiche WebLink

Home Browse Search

------------ APPLICATIOWFOR 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):• �: y "� k 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. a YDS. 10 Y y$r Job Address/ ' City Lot Size x l zd''i PM 'k Owner's Name µ Address,z `/�. r'+ o� ( Phone- JI } )Contrac Address/,R� License No32_ Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ F{J .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 i i { ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I ❑ Public ❑:Ofher ❑ Delta Depth of Grout Seal Type of.Grout_. ❑ Irrigation tl pprox. 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 er Material (Belo 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR DDITION 9 DESTRUCTION ❑ 1No septic system permitted if public sewer is available within 200 feet.) ; Installation will serve: Residencey Commercial_ Other Number of living units:� Number of roams —Zl� / 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 i Distance to nearest: Well Foundation Property Line Y LEACHING LINE` 11?""No'& Length of lines Total length/size FILTER,:,BED BED ❑ Distance to nearest: Well Foundation a Property Line 1 TER ; SEEPAGE PITS Depth Size _3 73- Number e SUMPS_ - C1Distance to nearest: Well /06' foundation/D 'Property Line X_ " DISPOSAL`PONDS ❑ ► 1.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:"' -- ----T-? The applicant call for all- uire inspections. Complete drawing on raver de. w Signed ;' V '� L` Title: / Date: FORDEPARTMENT USE ONLY 'Coll. f t ApplicationFAccepted by 1 r � _ ~' DateP5/ n Area �. t Pit or Grout Inspection by `+' Date Finahlnspection by Date / VN—I .aE �:'� I r�..�T r+... .sy++ k�l�v. k Additional Comments: tR` D Stk 466-6781 i❑ Lodi 369.3621 .1" I 0''Manteca -823=7104 —D Tl y 835-6385 Applicant-.Return all copiesTto:-Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2D09, Stk., CA 951201 1 FEE AMOUNT DUE AMOUNT REMITTED ' INFO CASH AECEIVEDyBY r PATE PERMIT 130. + EH1324(REV.I/R 5111 EH 114-26 ® _ - I