87-304 - Laserfiche WebLink

Home Browse Search

.Yj APPLICATION FOR PERMIT SAN JOAQUIN FOCAL. HEALTH DISTRICT .1601 E. HAZEL—I ON AVE., STOCKTON, CA Telephone (209) 466-6781 'f Y.-.. _z5- #ryn i�` -� -.. .. .,,il. • ',J',;- , - PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED 9 a, (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. 1.862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . J„'i , City Lot Size_-2_0 !Cs s PM ? , Job Address one ��yy 1� ck Address is��'r' , Ovrner's'HamsCJi~ U x5 —_ h { s License No. L ' Phone 0 L Q Contractor's Name - - ° TYPE OF WELL/PUMP: NEW WELL ❑ WELL R P:LACEM T 17 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM RE AIR ED] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SES DISPOSAL FLD.EWER LI PROP. LINE w I FOUNDATION AGRICULTORE WELL OTHER WELL— AREA INTENDED USE /TYPE OF WELL PROBLEMARER I CONSTRUCTION SPECIFICATIONS r ilia, of Well casing /TYPE ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. �1'�n Specifications t` ❑ Domestic/Private ❑ Gravel`Pack ❑ Tracy Type of Casing__ I t- ,t. ` V; Type of Grout ❑ Public ❑ Other ❑ Delta Depth of G`rout Sear r {- ❑ Irrigation --Approx. Depthx *D Eastern Surface Seal Installed by 41- . Repair Work Done ❑ Type of Pump n H.P:'t t W State Work Done Well Destruction ❑ Well Diameter Sealing Material`Itop 504' FilleraMater+al48elow 50`1 } Depth � TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADM ION,� �DESTRUCTION 4'❑1'i NO availseptiable c sy tem permitted if public sewer is Installation will serve: Res dence� Commercial— Other _ t- d Number of living units: Number of bedrooms ` W f�t1 *j Watemable depth Character of soil to a depth of 3 feet: ` —¢fir Type/Mfg l� ��1�� _e Capacity_ t:�= SEPTIC TANK � No. Compartments 1 � y Method of Disposal PKG. TREATMENT PLT. ❑ /] �- Distance to nearest-I Well 7 ` Foundat on.� Property Line - t t "r' i f i LEACHING LINE 1A, No. & Length of lines Total length/size C FILTER BED ❑ Distance to nearest: Wel} Foundation Property Line Size f Number SEEPAGE PITS ❑ Depth t SUMPS ❑ Distance to nearest:""—WeH— �Founda't on Property tine 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 Sbn,Joaquin LocahHealth:Distnct. Home owner a5-licensed agent's signature certifies the foll'olniin�: "1 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 Californi ." - t The applicant rrf 11 foraA:required in pections. Complete drawing on reverse side. i L _ � ' k' Date: ` Signed Title: { FOR DEPARTMENT USE ONLY s Date Z 'Z -�7 Areayt7 A/ Application Accepted by 3 i Date Pit or Grout inspection by Date Final Inspection by r A i[! w1.Gf` a t S h til- ►h kSr Additional Comments:P. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104) ❑Tracy 8355-6385 fj j2 Vx� �r Applicant-Return Al copies to: Environmental Health Permitl5ervices 1601 E. Hazelton Ave.; P.O. ox Stk., CA 5520�(,pgQ� �`�' ,, p � * / 7 t CK# FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH + Ex 1324 IREV.101831 EH 1426 ! a