87-3566 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 If 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. City Lot Size PM Job Address �. Address Phone 2-77 Owner's Name �� Contractor ��j L Address242-9-- 6-CA A License No.3 1L►E....,��+ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ll SYSTEM REPAIR ❑� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKk ` ' SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION �'t` } AGRICULTURE WELL OTHER WELL PITS/SUMPS " INTENDED USE TYPE OF WELL , AR0BLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ; 'EI Manteca ; Dia. of Well Excavation Dia. of Well Casing ( s i stic/Private D-Gravel�.Pack-..-•T. Q Tracy- - - - -Type of Casing Specifications {l Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation �—.Approx. Dept IJ�Eastern Surface Seal Installed by Repair Work Done �L.J-_Iype of Pump (� H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: ,NEW INSTALLATION I.') REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other �. Number of living units: Number of bedrooms �-- --� Character of sail to a depth of 3 feet: t ; Water table depth SEPTIC TANK ❑ Type/Mfg t Capacity_, No. Compartments PKG. TREATMENT PLT. ❑ 1 `� .F Method of Disposal s Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑- No. 8, Length of lines l Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ( Property Line' j - SEEPAGE PITS i k Depth Size Number SUMPS L1 Distance to nearest: Well Foundation i Property Line DISPOSAL PONDS ❑! I hereby certify that I have,prepared.this-application.and.that the work will be done in a&ordance 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 Lbe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor ia." The applicant u call fo all q i pe do Com ate drawing on re r e ' �� Signed Title: Date 9 4,� r- FOR DEPARTMENT USE ONLY Application Accepted by _1C •V\V) _ Date 22 Area 6 `� , Pit or Grout Inspection by "L Date Final Inspect/ion by �• Date I �g Xditional Comments: Stk 466-6781 11L i -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO r EH13.24 IREV.i/n 51 EH 14-28 � � � r— s�fo