87-4096 - Laserfiche WebLink

Home Browse Search

.n ,,. APPLICATION FOR PERMIT ?ITC; I SAN JOAQUIN LOCAL HEALTH DISTRICT _. 1601 E. HAZEL T ON AVE., STOCKTON, CA W ! Telephone (209) 466-6781 Z PL&+-,XPs 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District} 6?� , Job Address City het Size PM r // // 7] k Owner's Name r Address r Phone �P / s i� t /address / License No. �r � Phone_/ T Contractor TYPE OF WELL/PUMP: �i -- W WEL WELL REPLACEMENT L1DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR D OTHER ❑ /A0 ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �pf��' 1. W FOUNDATION Its AGRICULTURE WELL OTHER WELL PITSISUMPS �� r INTENDED USE w!TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v XIndustrial Open Bottom ❑ Manteca. Dia. of Well Excavation Dia. of Well Casing 4 ❑ Domestic/Private }Gravel Pack ❑ Tracy,' Type of Casing— Depth Specifications C I i Public ❑ Other ' Ci De a`, Depth of Grout Seal l� ✓ Tyge of Gr�o�uty�J_y�� IP I i Irrigation '�Approx„Qepth' l I Eastern`"II. '_: Surf ac Seat Installed by Repair Work Done ❑ Type of Pump��I �H P_ / State Work Dane V Y Well Destruction .❑ Well Oiamet r '` Sealing Material (top 50') (� Depth L.--=a - fF.iller Material 18elow 50') � t � TYPE OF SEPTIC WORK: ANEW INSTALLATION l l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is if available within 200.feet.) I 4�. -,.=..Installation wiiLserve:,,..Resid_ence__.,Commercial—t•Other Number of living,uriits: �� Number of bedrooms ` Character of soil-to a depth of 3`feet: Water table depth SEPTIC TANK s ❑ Type/Mfg Capacity No. Compartments l Method of Disposal PKG. TREATMENT PLT. ❑ ->,; - Distance to nearest: Well Foundation V� Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line a a! k SEEPAGE PITS I I Depth Size Number SUMPS Lei Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L1. 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. 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 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." 11: The applicant r require�f ns. Complete drawing on reeveetssi side. Signed X___G%� �I _-Title: --• �! S G Date: 107-11= 7 li FOR DEPARTMENT USE ONLY r draw�5 Application Accepted by Date L Area spection by Date Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 , O.Lodi ,369-3621 ❑ Manteca ' 823-7104 ❑ Tracy 836-6385 Y 'I"Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 li .I. FEE AMOUNT�DUE.. AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH13-24 IREV.t/H 51 '.�"•' mss V� P� I ! / EH 14-2a !1