87-2750 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVEz, 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 p made in compliance with San Joaquin County Ordinance No. 549 for sewage of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin t Local health District. l Job Address s — I Uy7 N F/,4,6 4� CityS�u t/ fff Lot Size PM p f h Owner's Nam 5�h W�/ olfMa"Css '11 7 /V► F,/ A," � Phone "---Contractor I Address - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EJDESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOVNIDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — 1-1 Public f-] O`ther ❑ Delta Depth of Gi-out Seal Type of Grout I 1 Irrigation uI�..Approx. Depth ( I Eastern Surface Seal Installed by i Repair Work Done ❑ Type' of Pump H.P. State Work Done_ Weli Destruction ❑ Weil Diameter Sealing Material (top 50') a Depth x. Filler Material (Below 50') `r TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION)< (No septic system permitted if public sewer is I available within 200 feet.) r Installation will serve: Residence_ Commercial____ Other Number of living units: ll Number of bedrooms % Character of soil to a depth'of 3 feet: Water table depth SEPTIC TANK ❑ -Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ' Total length/size = - FILTER BED ❑ Distance to nearest: Well Foundation Property Line 0 _ SEEPAGE PITS ( I depth Size Numberlip i SUMPS Ll 'Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ !IC, f 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. `. Home owner or licensed aged's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I snail 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." The applicant must call for alllwired inspections. Complete drawing on reverse side. �! Signed Title: /'�''�/� Date: 7-'st d —7 7 R DEPA TMENT USE ONLY Application Accepted by Date — Area I Pit or Grout Inspection_by Date Final Inspection by Date r Additional Comments: } LJ Stk 466-6781 ❑Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO. INFO CASH y ♦ EH 13-24(REV.i/as 5) �, r 7�5� EH 14-2e I v`'� -—ti4 �r _.. - i `—` -�•