87-3833 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT =4 SAN JOAQUIN LOCAL HEALTH DISTRICT 3 ' 3i3 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED R (Complete in Triplicate) Application is hareby 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /(_✓644_4-P— Job Address �y ( i12/I-SPL I f Cf'Ct3 [�l=s,�V�1�� City ` Y (A Lot Size PM CA) Co C-E3"7x/F Na-S4 n I IINW LJ I Al � Owner's Name Address /O Phone 1n+ �; '' � �'N}N j�;.�•+ r� J 'i� ��V Contractor IM,h ° Z -_Address ZO 1v G 1 License No. Phon TYPE OF WELL/PUMP: ,j NEW WE WELL REPLACEMENT ❑ DESTRUCTION © /vfGfU( ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I�� DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES / DISPOSAL FLD.____ PROP. LINE 10/7- FOUNDATION AGRICULTURE WELL jOTHER WELL •17.4fltfPITS/SUMPS/ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation__L_U Dia. of Well Casing ❑ Domestic/Private T5<Gravel Pack Tracy Type of Casing Q\)G Specifications f`i Public (l Other ❑ Delta Depth of Grout Seal 'L/r� Type of Grout - r I I Irrigation `L _Approx. Depth I 1 Eastern Surface Seal Installed by - C - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction © Well Diameter Sealing Material (top 501 n: Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATtO EPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is ` available within 200 feet.i f,. Installation will serve: Residence_ Commercial - Other Number of living units: Number of bedrooms. kCharacter of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ ii Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ 1i Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ ;� No. & Length of lines Total length/size FILTER BED ❑- Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 li Depth Size Number SUMPS Cl'; Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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. e Homowner 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 Cal• ornia." The applican st call f r all aqui✓ d "Hsps ons. Co plate drawing on reverse side. Signed X Title: Date: �. II F DEPARTMENT USE ONLY Application Accepted by Date L `� —7 Area 17 . 0 Pit or Grout Inspection b Date d 3A Final Inspection by Date �� 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 95201 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-241REv.1/H 5f EH 14.26 r ��