87-2847 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT t �� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 welt/pump and the Rules and Regulations of the San Joaquin Local Health District. I C OAILot Size PM Job Address � City�, Owner's Name 9, 4 eAddress Phone t jiCf/3TTX Contractor 5 Address License No. #9 -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 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �`�'� "�� S ecificatians" r�4 ❑ Domestic/Private 1-1GravelPack ❑ Tracy Type of Casing p .`I I'! Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by - i< Repair Work Done ❑ Type of Pump H.P. _. State Work Done GV TV_COs` Well Destruction Well Diameter Sealing Material Itop 50'i G� .amu J1t Depth fp0 _ Filler Mei terial iBelow 50'1 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDiTION:I-1 'DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l '{ Installation will serve: Residence_ Commercial_ Other :. { j Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: ? Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ( PKG. TREATMENT PLT. E) Method of Disposal 1 Distance to nearest: Well Foundation Property Line l i t LEACHING LINE ❑ No. & Length of lines 4 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line k 1� lt' SEEPAGE PITS i I Depth Size i Number ' F SUMPS ❑ Distance to nearest: Well Foundation Property Line I 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: 1 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." The applicant or II requi ctions. Complete drawing on reverse side. Signed X Title: 1 Date: 71,12-& R DEPART MEN USE ONLY 3 I i Application Accepted by Date _ Area_ Pit or Grout Inspection by Date F nal Inspection by Date Additional Comments: ___ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑;Tracy 835 63$5 t�s i A[ppli�ant "Return all"copies to: Erivironrrlentel Health Peimit/Serve—`cesJf6a1"E'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. t � S+.EH53-241REV.i�Ks1 EH 1428 —�--.