87-509 (2) - Laserfiche WebLink

Home Browse Search

it ^ I! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED it (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. Job Address za Id I City S�A_J Lot Size O J3C7 PM Owner's Name 774PUCmeAJe[/arl Address 5 1 9E _ Phone i Contractor JCLd�D__�• /1117 Address Zt0X_R)• G4 License No.<lA�7E - Phone 32 7 : TYPE OF WELL/PUMP: iI NEW WELL ❑ WELL REPLACEMENT ❑ 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx, Depth ❑ Eastern Surface Seal installed by + Repair Work Done ❑ Typelof Pump H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 501,� Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION a REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is II F �� f.ti available within 200 feet.! Installation will serve: Residence_ Commercial— Other y_ I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water,table depth i SEPTIC TANK ❑ Type/Mfg � Capacity " No. Compartments PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well Foundation �Property Line. L'EACHING'LINE '� LI--4o'4& Length of lines' M Totaflength/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size m i Number { SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ II 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, 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 must call for all required inspections. C plate drawing on reverse side. s Signed Title: = Date: �I I FOR DEPARTMENT USE ONLY y Application Accepted by Date Area u I Pit or Grout Inspection by Date Final Inspection by Date ��,,,� .�--�'6'�`+w.-- ...ati..�r.... , .y,�.,_-..:::..tea.,..-.,. v-w-... ,......oma•....- -.-,.�..�..... _.,r Additional Comments: / t ❑ Stk 466-6781 ❑ Lodi, 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all copies toi Environmental Health Permit/Services 1601 E.•Hazelton`Ave., P.O:Box 2009, Stk., CA 95201 .� � r tK r �J.• w r' .e PEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'Np. INFO I CASH it 3-241R , / + EH 1EV.1/a5] ✓I. r 3 s 7 / / �y��/ ■ " • ��/ EH 1428 #'