87-2765 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t�;• (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 District. NA Job >�(L � � Job Address f �I� � City Lot Size PM Owner's Names f� a ale S Le-9L Address 87 f u E' c f Phone H 22 Contractor r[.0 Address icense No. Phone V–11 TYPE OF WELL/PUMP: U NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION CJ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �O�THE�R ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES DISPOSAL FLO. 4 PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation ' Dia. of Well Casing Domestic/Private AGravel Pack XTracy Type of Casing RYG Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of rout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth -2151Filler Material (Below 501 T OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is I available within 200 feet.) Installation will se esidence_ Commercial Other Number of living units: u edrooms Character of soil'to a depth of 3 feet: Y Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation roperty tine LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ + 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 F certifies the following: I certify that in the performance of the work for which this permit is issued, I shall employ ersons subject to workman's com nsa- ' fy pe P Y P 1 Pe L tion laws of California." z» The appli ant must call for all re i ed inspections. Complete drawing on r erse s e. 3. Signed X Title: ' Date. — A" A?7 FOR DEPAR MENT USE ONLY Application Accepted by Date vU J� Area Pit o ! ; nspecti6n by Date Final Inspection by ate Additional Comments: Stk 4W6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835M85 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.r CA 95201 , ti FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24PIEV.I/asl EH W25