87-2344 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT a, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 5 go Welz R,00M Telephone {2091 456-6781 -a?p ()er— �AUCi.4 PERMIT EXPIRES TYEAR FROM DATE ISSUED Q C°R�ER i (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 Local Health Distri t. S � Al- Job Address �scA LOW -- 13F TA ROA D aon City I—PJ D aN Lot Size L100 IM- PM Dwner's Name, FoSTjze :&R Kms,/ FAR-1 S AddressDAyis SF +v/N GS 7-6 ki. CA Phone Es r6 9 ttWN _4'k-4 N"i ,� Cantra`�ctor-- �5riif�l�, Address N License No. Phone TYPE OF WELL/PUMP: . L,_ L!,NEW WELL ❑ , _ - WELL`REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION F1 «.,..SYSTEM REPAIR ❑ � OTHER.❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 44-k-4' ' a DISPOSAL FLD. PROP. LINE 3 >� FOUNDATION AGRICULTURE WELLA 1 t 1 OT•HERJWELL t�CA s�` PITS/SUMPS ' INTENDED,USE TYPE OF WELL PROBLEM AREA-CONSTRUCTION SPECIFICATIONS s"'�-- 1� 171 Industrial 1 11 Open Bottom f ❑ Manteca Dia. ofMell Excavation a - ^' J,Dia`of-,Well'Casing F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type.af Casing ' , f Specifications f'l Public F1 Other 'w W,❑ Delta •^ Depth of Grout Seal Type of Grout ' I Irrigation _-Approx. Depth l I Eastern Surface Seal Installed b rN. +►-rt; � _ g' y Repair Work Done ❑ Type of Pump H.P. ;t. !State Work Done Well Dest uction ❑ Well Diameter Sealing Material (top 50') i ;%, I Filler Material (Below 50'1 I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I i DESTRUCTION 11 (No septic system permitted.if public sewer is 11 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other �'10p✓ Number,of living units: 'Number of bedrooms�_ { . r.' t Character of soil to a depth,of 3 feet: Water table depth 8EPTIC,TANK k- Type/Mfg Capacity 2.00 LrI No. Compartments PKG TREATMENT PLT. ❑ / rMethod of Disposal P Sly x `p Distance to nearest: Well Foundation Q Property Line�/_V) --� :-- . y. _�L' ., EACHING LINE No. & Length of lines _3 —�DQ Total length/size FILTER BED ❑ Distance to nearest: Well = Foundation{1St�. . Property Circe' � I SEEPAGE PITS I I Depth Size 'A t N-ft [Number ( d SUMPS ❑ Distance to nearest: Well !!#- `V XFoundation { Property Line DISPOSAL PONDS ❑ a, i 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. ,- 1 Home owner or licensed agent's signature certifies the followings "I certify that in the performance of'the wdrk: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 followingr"I certify that in the performance of the work for which this permit is issued`1 shall-employ persons subject to workman's compensa- tion laws of California." The applicant must call for oorrralllrregquuired ins �pections. Complete drawing on reverse side. Signed X `.t' \NTitle: ©It�IZ e!^ Date: 6-LGA�7 i AjFOR DEPARTMENT'USE ONLY Application Accepted by tt .k Date Area ., Pita Grout Inspection by Date �Final Inspection by=i' � e Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 " ` y❑ Tracy '835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. + EH1324IREV.ti H5) EH 14-28