87-4278 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT ' i` I: 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 4.66-6781 I 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. Joh Address �I ,e Sri. e �ti� City Lot Size Ply I Owner'sNalTe L r, /I C�cn!oG Address S�'IY� Sa' C�rokeC' LeLv,C. Phone C��33q-3gg0 1. * ,, f It- .r„ L- eoxCkwti1- + C.a^S1AA w•w� V%3153 Vrh S e ,s1-.V ler.+Sa_v► !! r., [q 4S' 44 Z-7 Y—7L-- i Contractor Ccs[�r�.--D(Z 1ItVS Address '//6 711 Q(ri �. rlPrnoq�C/'� License No.46�3Z y Phone Y1 &S'r TYPE OF WELL/PUMP: J NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I m9ni f°r,l Lhet[ 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 f Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Q Tracy Type of Casing ++40 hIVG !`l Public Specifications L7erreN.,�, f�,,, Other n Delta Depth of Grout Seal Type of Grout 15-76 {C I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work re ` Well Destruction Well Diameter Sb Sealing Material {top 501 &VVAAI ` ��f� r11oni�on03 L1t�4 Depth —k--70" Filler Material (Below 501 Q� TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is 1� Installation will serve: Residence— Commercial_ Other available within 200 feet.f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I 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 I SEEPAGE PITS I I Depth Size SUMPS Number - L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Il 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 his permit is issued,I sh 11 employ persons subject to workman's compensa- tion laws of Calif ia." The applicant u t call for all revu r inspections. Complete drawir P g on reverse sid8 Signed Title: Date: /2--7!.ff 7 FOR IDEPARTMENT•USE ONLY C� CCS �/FAA Application Accepted by I, „ j f�� /� / Date k[ Area 1 Pit or Grout Inspection by p. Z ccr- Date 12 14rn- p y q �5 Final Inspection b o,v� a,r Date Additional Comments: at� ❑ Stk 466-6781 ❑ Lodi 6 369-3621 CI Manteca 823 7104 ❑ Tracy 635-6385 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 INFO RECEIVED BY DATE PERMIT'NO. EH 14-29 + EH 1324(REV.t j�,