87-1649 - Laserfiche WebLink

Home Browse Search

r y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209).466-6781. r 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. / Job Address City Lot Size PM ��U K� �_ Owner's NameL 4 AddressD.16 Phone Contractor's Name C- License No. Pho TYPE OF WELL/PUMP: ti NEW WELL ❑ WELL REPLACEME DESTRUCTI N1 PUMP INSTALLATION ❑ SYSTEM REP IR 0TH "V DISTANCE TO NEAREST: SEPTIC TANK � ER LINES '- POSAL FLD. : PROP. LINE t FOUNDATION AGRICULTURE WELLOTHER WELL ;PITS/SUMPS Q v INTENDED-USE—-TYPE-OF-WEL-L----PROBL-EMAREA�CONSTRUCTION-SPECIFICATIONrS El Industrial D Open Dia of Wei Casing n Bottom ❑ Manteca Dia. of Well Excavation g (� Domestic/Private ,Gravel Pack ❑ Tracy x= T.ype of Cssing Specifications &i� l t" f Ty e"of G rout OY ❑ Public Q Other ❑ Delta Depth of Grout Seal [7 Irrigation $(J1�PProx. Depth ❑ Eastem�-`4Surface• eal Installed by { x Repair Work Done Type of Pump \q� H.P, State Work Done` " C.—Ek Well Destruction ? Well Diameter ,Sealing Material (top 50') Depth Filler Material (Below 501 �=, e ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑, REPAID/ADDITION%.❑ DESTRUCTION ❑C(No septic system permitted if public sewer is available within 200 feet.) 4 Installation will serve: Residence— Commercial— Other t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: fi? Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments P -t Method of Disposal KG. TREATMENT PLT. ❑ i Distance to nearest: Well .Foundation Property Line ? �. Total length/size LEACHING LINE ❑ No. & Length of lines 1 FILTER BED ❑ Distance to nearest: WellFondation4 � Property Line [ SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �6 I hereby certify that I have prepared-this-application andthat.the work-will be done in accordance with San Joaquin county ordinances, state laws, and r 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 this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applic for all required in Ions, ompie drawing on re rse side. ' Title: Date: k Signed FOR DEPARTMENT USE ONLY Application Accepted by Date ~� Ar Pit or Grout Inspectio b Date `3� Final Inspection by Date3? Additional Comments: T � a1� ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 7104. ❑ Tracy 8355-M Applicant-Return all copies to: Environmental He h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEECK RECEIVED BY DATE PERMIT"NO. INfO AMOUNT DUE AMOUNT REMITTE CASH p +EH 13-24 tsEv.sorsa} 'v__ EH W26 sE _