87-3675 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 . 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.' ' Job Address City C(; Lot Size PM Owner's +�+ V' dc3?` Phone Contrad_4 uk(�LD&")Address f +O� License No,�Ir� Phone TYPE OF WELL/PUMP: NEW WELL ❑ A WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES I' DISPOSAL FLD. PROP. LINE + a y. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �n ❑.Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack-- ❑ Tracy Type of?Casing- Specifications— €'1 Public t ❑ Other 71 Delta Depth of Grout Seal Type of Grout _ I Irrigation —;Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ t Well Destruction Cl Well Diam6t r Sealing:Material ltop.50'1 Depth Filler Material (806W' 501. r• J# TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1-1 DESTRUCTION KIM septic system permitted if public sewer is available within 200 feet.I 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 SEPTIC TANK `- ❑ iType/Mfg ti' Capacity 4FNo. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal je , � i Distance to nearest: Well Foundation Property Line I LEACHING LINE ; ❑ }No & Length of lines Totat-length/size ` FILTER BED ❑ -�Distance to nearest: Well Foundation Property Line s l SEEPAGE PITS l#j Depth """" Size r.= _ Number t SUMPS ! j kDistance to nearest: Well Foundation Property Line DISPOSAL,PONDS I hereby certify that I havel.prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of thkS1pn Joaquin Local Health District- 1 ; Home owner or licens aWnt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not j employ any person i uch manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature ' certifies the followin . "I certify that in the perfor f the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ca' ia." i Th m call for at] u re ' q - peciions omplete drawing on re a side. �( Sign Dater / 1 2 . -.. -. w... .___Et'3R_D.EPARTMENT.-USE•ONL-Yom. ... Application?Accepted byy M Date f Area Pit or Grout Inspection by ' - Date riiW'Inspection by Date w Additional Comments: 4 / r _ rr�vt.�C�UJ-44 GAG ❑.Stk 466-6781 ❑ Lodi 3694621 ❑ Manteca 8.23-7104 ❑`Tracy. (335-6385 n Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. a EH (37tl3.24 V9-26(REV.tirs5) lf5,lI�C3� ��_� EH 11-26 �_ r