87-3724 - Laserfiche WebLink

Home Browse Search

t _ APPLICATION FOR PERMIT l' SAN .IOAO.UIN LOCAL HEALTH DISTRICT �! 1601 E. HAZELTON AVE., STOCKTON, CA *; Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . w (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. Of s Job Address . Ciry Lot Size (400 X PM I q� Owner's Name Address �� / �j� 1 49Phone I &, Addressucense Contractor r /r-xv No - � Phane r . TYPE OF WELL/PUMP: NEW WELL- WELL REPLACEMENT ElT DESTRUCTION ❑ 1 + PUMP INSTALLATION Q SYSTEM REPAIR ❑ OT ER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES C/ J��i �._ DISPOSAL FLD.1�-PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFlCAT ONS ❑ Industrial _,. .„.❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing Domestic/Private -Gravel Pack racy Type of Casing L SpecificationsI6 ❑ Public ❑ Other t ❑ DeltaDepth of Grout Seal T 1 * - ype of Grout le ftA1111 ❑ Irrigation ---Approx. Depth ❑ Eastern° Surface Seal Installed by (2&-k2 �- Repair Work Done ❑ Type of Pump H.P. State Work Done Wel! Destruction ❑ Well Diameter Sealing Material (top 50') r Depth Filler Material-(Below 501 YPE OF SEPTIC_W_ORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if p' sewer is s available within 200 feet.) Installation rve. Residence_ Commercial_ Other I Number of living units: .Number of bedrooms N Character of soil to a depth of 3 e Water table depth SEPTIC TANK..• -" ❑ T e/Mf �. ' YP g Capacity No. Compartments € ; PKG. TREATMENT PLT. ❑ Method of Disposal I F F71 Distance to nearest: WVell Fo on Property Line r ` LEACHING LINE 0 No. & Length of lines " Total a size FILTER BED ❑ Distance to nearest: Well /.Foundation Property Li SEEPAGE PITS ❑ Depth Size i Number ' SUMPS ❑ Distance 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 i rules and regulations of the San Joaquin Local Health District. t� s"" Home.owner or licensed agent's signature certifies the followings"I certify that in the performance of the work for which this permit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation laws of Califomia."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 all for requi i spections. Completes drawing on r verse side. r Signed Title: Date: } FOR DEPARTMENT USE ONLY / Application Accepted by Date Area U Pit or Grout Inspection Date�d Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3693 1' ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO." i + EH 1}24(REV. e3) toEH 1428 f �/