87-3294 - Laserfiche WebLink

Home Browse Search

N. APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT `- 1601 E. HAZELiON-AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) l 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 Local Health District, 1 4 1 Job Address �.a LJ- 1 14\n. . 54 Yy&'� , City Trac Lot Size__153X 30�" PM r rrII Owner's Name C u V`V'0.k Spm aAddress 4 l-} �lfione 3 400 V Contractor At S t!gddress.25�_5_20u_ ), o-1), / License No.4 �76 Phone �s TYPE OF WELL/PUMP: 11 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Sot OV11K'S PUMP INSTALLATION LJ REPAIR ❑ OTHER C� VVIDIZ r' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL C I IIS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation z Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack [Tracy Type of Casing_ P VG Specifications 1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal1671 Type of Grout !W ❑ Irrigation U�LApprox. Depth 11 Eastern Surface Seal installed by d Yrt 5 Repair Work Done ElType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth.^4 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted it public sewer is Ns available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth o SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments �- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well FoundationProperty Line DISPOSAL`PONDS F7 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. - - j' 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 laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify the n the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws ifornia." The app cant u t all f r I r d pspections, mplete drawing on reverse ' Signed Title: Date: FOR DEPARTMEN USE ONLY l �] Application Accepted by Date_,.:Lp M =1Area Pit ornspection by Date Final b Inspection 'S" t 141' P y � Date , Additional Comments: ;, f ❑ Stk 466-6781 ❑ Lod 369-'1Ul ❑ 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 REMITTED ICZ INFO cAffR, RECEIVED BY DATE PERMIT"NO. 4 EH 1324(REV.7/e 5) 1 EH 14-26 CA.-' ��LI�