87-2855 - Laserfiche WebLink

Home Browse Search

ti 4 APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Rules and Regulations of the San Joaquin t Local Health District. ,r, ]�"cr `� _ City OC Lot Size�tiLF f4 - PM Job Address ,1. � - Owner's Name �!.r...r�zy fdYl Address Phone Contractor, Address�J r--6aT1 4 � -eer+yo 3 License N f Phone TYPE OF WELLlPU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL.:FLD. i ,PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL�—T PITS/'SUMPS r INTENDED USE ITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSI ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j M Public Cl Other Ll Delta Depth of Grout Seal Type of Grout <<" I I Irrigation s ..Approx. Depth I I Eastern Surface Seal Installed by _ I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter f Sealing Material (top 50') ; Depth � Filler Material (Below 50'I � ?: TYPE OF SEPTIC WORK: NEW INSTALLATION 1] REPAIR/ADDITION I,XIDESTRUCTION I I INo septic system permitted if public sewer is 1 # available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ' Number of living units: I! Numberofbedrooms I I Character of soil to a depth of 3 feet: i t Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑. Method of Disposal a Distance to nearest: Well Foundation Property Line- } LEACHING LINE ❑ No. & Length of lines Total lengthtsize - FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'1 Depth Sizes Number SUMPS Distance to nearest: Well Foundation ^�'fit PropertyL`ine DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in accordance'witffSan Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. -�-� I Home owner or licensed agent's signature certifies the following: '9-certify that4n-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 fpr which this permit is'issued,I shall employ persons subject to workman's compensa- tion laws of California." 1 (4 '-% — The applica st c I or.all req uir in ions. Complete drawing on reverse side. Sign— X Title: Date: 4 ,,RR FOR DEPARTMENT USE ONLY Application Accepted by wi,LA ti Dareck Area Pit or Grout Inspection by Date Final Inspectionb Date /� ll � Additional Comments: 11- i �l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma teca 623-7104 ❑ Tracy 835-My Applicant - Return all copies to: Environmental-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT D'JE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. ♦.EH13-24 1REV.1 i 8 5) /��A j' _ EH 14.26 y