87-1669 - Laserfiche WebLink

Home Browse Search

r iF APPLICATION FOR PERMIT J 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) 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. ; 1 ;; /� Job Address I V F Cityr Lot Size PM Owner's Name AddressG�} �i�2rl�11, Phone n � m�&rd,CA (&'y raA i Contractor G� f- G. Address Z. i�z+" r011 License No.3741 SZ.�Phone I6)7a3 7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q DISTANCE TO NEAREST: SEPTICTANK SEWER LINES . --,DISPOSAL FLO. PROP. LINE ID FOUNDATION �� AGRICULTURE WELL "' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation n Dia. of Well Casing inC� q ❑ Domestic/Private JX Gravel Pack ❑ Tracy Type of Casing 5 -40 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �,J TgL2L i Q Irrigation 45O" �t i�pprox. Depth ❑ Eastern Surface Seal Installed by ut Repair Work Done ❑ Type of Pump H.P. State Work Done ryriW,elll Destruction ❑ Well Diameter Sealing Material (top 501) f1i I'IQDepth V Ise �' Filler Material Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo 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 1 ❑ 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 ❑ Depth Size 7° SUMPS 1-1DistanceDistance 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 Sart 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."Contractoes 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 i9 ctions. mplete drawing on reverse side. Signed G Title: r s Date: `9 i FOR DEPARTMENT USE ONLY Application Accepted by Date Z /,i' Area Pit or Grout Inspection byo�d_ ✓� Date �� Final Inspection by 1�X n.� _ Date Additional Comments: A ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUE. AMOUNT REMITTED INFO $H RECEIVED BY DATE PERMIT NO. r + EH 13-24 IiiEV-t/a 5) EH 1428