87-25 - Laserfiche WebLink

Home Browse Search

394 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Ryles.and Regulations of the San Joaquin Local Health District. Job Address 3 ': ` ' Cityr r Lot Size { zv' _ PM 3 Owner's Name., d ress�� P YiLs �"`-= — Phone.3 `--� Contractor li Address_130 License No/�2_21Phone J (°k Jr13J TYPE OF WELL/PUMP: NEW WELL ❑ 'WELL REPLACEMENT ❑ 'DESTRUCTION ❑ PUMP INSTALLATION ® SYSTEM REPAIR.❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE W 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 B'Dornestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta ^r Depth of Grout Seal Type of Grout ,. ❑ Irrigation --Approx.. Dep1h ❑ Eastern -'Surface Seal Installed by Repair Work Done 9' Type of Pumr�y'�yyj i p H.P. 1 'State Work Done Well Destruction ❑ Well Diameter 1 Sealing Material(toj+150;) Depth - x*M. n Filler Material (Below�50') TYPE OF SEPTIC WORK: NEW°INST"A-ELAT(ON`❑—REPV b S'i"�Cl l C] (No septic system permitted if public sewer is I ---^-`-- available within 200 feet.) `Installation will serve: Residence! Commercial— Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 t Method of Disposal . Distance to nearest: Well # Foundation Property Line LEACHING LINE .. Len&h- -' ' ' ,��No:& Length of-lines,-��`-�'�_._._...._-.z.__.___.._.__._._.___....____Tztal.length/sizev---- _-- " FILTER BED ❑ Distance'to nearest: Well Foundation Property-Line i SEEPAGE PITS ❑ Depth ''# Size Number 1` SUMPS ❑ Distance''to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 San Joaquin`Local Health District. t, Home owner or licensed agent's signatuFe: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 tc(become subject to workman'skompensation laws of California." Contractors hiring or sub-contracting signature certifiers 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." I`1 ✓` i it?rs The applicantmust call for uired'ihs etions. Complete��drr/awing on reverse side. Signel^2Tlta12�` Date:'�� d X le: !!' FOR DEPARTMENT_ USE ONLY " Application Accepted by 1'I } Date A-1797Area 1)21 a Pit or Grout Inspection by Date ! Final Inspection byl Date Additional Comments: - L ❑ 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 K 0 INFO AMOUNT DUE'_, AMOUNT REMITTED` CASH RECEIVED BY DATE PERMIT'NO. + EH13-24 CREV.1/e 51 EH 14-26 h