87-2921 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED—' r (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 DeCiry S +slr1 Lot Size PM ry . 3 Owner's Name" Address 'Phone" Contractor Address AOX 114 License No. :Z C�at Phone - ,T a 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ In Ll Open Bottom E-1MantecaDia. of Well Excavation Dia. of Well Casing ❑ Domestic/Peivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Y❑ Other ❑ Delta r Depth of Grout Seal Type of Grout ❑ Irrigation 4, l�Approx:_Depth C1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done E Well Destruction '❑ Well,Diameter Sealing Material stop 50'1 Depth Filler Material IBelo_w 501 TYPE OF SEPTIC WORK:!- NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet./ Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms_f� Character of soil to a depth of 3 feet: cI Water table depth SEPTIC TANK K Type/Mfg Capacity_ _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal __Distance to nearest:._., _.Well ,Foundation *-��} Property Line LEACHING LINE U No. & Length of lines j — �o Total length/sized 14 FILTER BED ❑ Distance to nearest: WellIrl) Foundation - .a-�-. Property Line - r SEEPAGE PITS, (Depth ! i Size "1 $.1 IQ NurriEber SUMPS ❑ Distance to nearest: Well. �cj' F'ou'ndation* �] _` Property Line i DISPOSAL PONDS ❑ X;. ,1•- j hereby certify that I.have prepared this application and that the work will be done in accordahce with San/Joaquin county ordinances, state laws, and j 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 woik fo'r Which this permit is issued,-1'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 ymust `call .for all required inspections. Complete drawing on reverseJide. Signed X Title: I.l� F Date: —7 FOR DEPARTMENT USE ONLY Application Accepted by `Date J � Area K .13 v-,Pit or Grout Inspection by Date Final.In4mction,by Date E Additional Comments: ❑ 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 95201CK FEE ; INFO AMOUNT.DaUEE� AMOUNT REMITTED CASH RECEIVED BY DATE ti �PERMIT''NO. { "- + EH 13-24(REV. EH 14-25