87-3056 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 u 4 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) / P 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 /�Lr �� City Lot Size PM Owner's Name C A51Z ,�, diff Address cYl7/z6. fp Phone . dd Contractor l✓,S ress /1t� f 1f-MAe License No. 1 Phone ---r- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,� vC; ,� Y M 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of-Well-EZcavation 'Did:-of Well Casing Vu s til ' "Domestic/Private 0 Grave LierPack 171 Tracy Type of Casing Specifications Y ("i Public Other F1 Delta Depth of Grout Seal Type of Grout r • I I Irrigation Approx. Depth I I Eastern S/ ace Seal Installed by _ Repair Work Done El Pump -�- H:P:R— - State Work Done Well Destruction ❑ WerF6iameter Sealing Material (top 50') Depth- '' " - Filler�Material lBelow 50'1 fir.. .-- I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ Comrrtercial- 1 Other Number of living units: Number oft edrooms ' "s Character of soil to a depth 3 feet: P r Water table depth SEPTIC TANK ❑ Type/Mfg• Capacity — No. Compar ments PKG. TREATMENT PLT-^D Method of Disposal Distance-to-nearest; —. ,Well Foundation Property Line LEACHING LINE ❑�No. & Length of lines Total length/size FILTER SED r ❑ Distance to nearest: Well Foundation Property Line # f I SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line t 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 SanlJoaquin Local HealthDistrict �t Home owner or licensed agent's signature certifies the fbllowing: ";j certiNy i' at-ih 16e�performancet f 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 certifyMthat.inthe-performance of,the work.for_which this.permit is.issued,_i.shali.employ-persons-subject,lo.workman's.compensa- -- tion laws of California." I � The appfioant f,. gal61148guctions. Complete drawing on de. Signed X Title: �� Data.- FO DEPARTMENT USE ONLY /gam �pApplication Accepted by Date — 29 Area Pit or Grout Inspection by Date Final Inspection by Date o Additional Comments: L1 Stk 466-6781 ❑ Lodi 369-3621 Ll 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 A UNT REMITTED CASH RECEIVED BY DATE PERMIT'tJO. + EH 13-24(REV. /rs 51 ` " / _�/f EH 14-2B J (f I