87-4035 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA fTelephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ttti (Complete in Triplicate) I 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 II 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$an Joaquin i Local Health District. ,. Job Address` e City L'ot Size 0z'*.jOe PM Owner's'Name A/A 14 r f? o �ptdmess Phone Contractor Gontractar Adf.!dress e �License No. . Phone !' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Vis. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .. DISTANCE'TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP,,LINE Ecti FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS- INTENDED ITS/SUMPSINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V V e ❑ Industrial ❑ b?pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l]V ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificationst i {`l Public Cl Other Cl Delta Depth of Grout Seal '.i `e `•Type of Grout,� _ I I Irrigation _LApprox. Depth { I Eastern Surface Seal Installed by .,w,- w l _ � �r � A Repair Work Done C7 Type'of Pump H.P. State Work Donet Y t_ v Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material f _ TYPE OF SEPTIC WORK: NEW INSTALLATION -•REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is - available within 200 feet.) i. fxf �—_ nstalfation will serve Residence n Commercial Other Number'bf living units: —I-- Number of bedrooms 4 'Character tof--soil too-a depth of 3 feet: A : ' Water table depth tom, ER`Fltr TANK Type/Mfg � �} Capacity No.,Cotnpartments % PK EA dVIENT PLT. ❑ '! Methb&o.f Disposal Distance to nearest: Well Foupdation •Property,Llne'`- w 1 s LEACHING LINE I + No. & Length of lines �_� tr Total length/size - 1 FILTER BED ❑ Distance to ilaresf:-` 'tNell�_�jFoundation'— {Propeny'it�e �1r 1 � 4•'i �� YF-.-^�r..w.y¢*1w�"__��r..9'7 ��+w....4':::M 1* SEEPAGE PITS I ) Depth ' �- Size ��xi`' " Number `: 1 SUMPS Distance to nearest: Well `t- {Foundation Property Line 1 DISPOSAL PONOS 0 ...._E--.. ._-..........,--•--. �� ---.._=`.''..,.._.._....,......w..,,.�.... 4+ � 4 I hereby certify t t I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,6tatel1. laws, and rules and regulati ns of the San Joaquin Local Health District. r ! j, Home owner or fi ensed agent's signature certifies the following: "I certify that in the performance;of the work for which this permit is issueL shall not employ any persoln in such manner as to become subject to workman's compensation laws of California."'Contracior's.hiring or sub-contracYHig signature certifies the folloWing:_:7.certify-that4an the performance of the work for which this permit is issued, I'hall employpersons subject to'workmen's compensa- tion laws df Califdrnia." I. The applicant rnust call fo II required inspections. Complete drawing on reverse side. Signed X '.. 7t�F .__.._._._— Title: �,erae,- a 2r. t __� Date- [. °: -'�'� Tom.--�«" € ., FOR DEPARTMENT USE ONLY 1. .. ;;�/� �!/ Application Accepted by „ Date Araamr`f=-- I Pit or Grout inspection by I fate Final Inspection by+ •-:Date r � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca _823-7104 # ❑ Tracy _-�_ -_M_...._. �, Applitia7it-="Return-alt"copies-roc Environmental Health Permit/Services„1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 FEE CK INFO AMOUNT DUE "% AMOUNT REMITTED CASH RECEIVED BY DATE -�PERMIT'NO. + EH 13-24 TREY. /n 51 / qd E 4-28 M - _ T.t:.-