87-2478 - Laserfiche WebLink

Home Browse Search

F z APPLICATION FOR PERMIT k91 SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone {209} 466-6781 € PERMIT EXPIRES TYEAR 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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. p i til C� Lot Size�a Qx ?7�M P Jab Address -+ � � 9 City Owner's Name 7/ �. R 1+1 J V1 T'.Address E4 A4 b IV Phone � 0 ffle Contractor AVY S 10 7` Address S /9 License N,. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM 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 Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications k 11 Public f 1 Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation W____-Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 , Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION LI DESTRUCTION X(No septic system permitted if public sewer is vailabie within 200 feet.) 4 Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms IIII Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity u No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: I Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS D Distance to nearest: Well ' Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 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 taws of California." Contractors 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 Califor ' . The applic t t call for all quired inpections. Complete drawing on reverse side. -- Signed X Title: C(T,�_Q Date: +;" Z — e 7 FOR DEPARTMENT USE ONLY Application Accepted by Ok&WDate Area Pit or Grout Inspection Date Final Inspection by Additional Comments: -_ f te; _3 ❑ 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 INFO AMOUNT DU'E AMOUNT REMITTEDr GSH RECEIVED BY DATE PERMIT'NO. E + EH 13-24(REV,aiHSf II EH 14-2e j I