87-769 - Laserfiche WebLink

Home Browse Search

y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`TON AVE., STOCKTON, CA 4 Telephone (209) 466-6781 PERMIT EXP4RES 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,// / s/ , Job Address ! 3 Q —0 2 ,�/-> A City/ v Lot Size e eR �,� Owner's Na �_, r? Address ., . y , Contractor's Name �/ /j�Ny`c�'License No. P�o TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATI N �"^ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK /LI ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 'HYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT � 6— ❑ Industrial '•`-.; vF—Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing ,429 I�Gravel Pack ❑ Tracy Type of Casing _ Specifications 1 ❑ Public O 044r ❑ Delta Depth of Grout Seal d Type of out -� :❑ Irrigation ---Approx. Depth ❑ stern /S Seal Installed by Repair Work Done El Type of Pump ILH.P. L- State Work Done Will Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 CD TYPEOF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence T Commercial_ Other Number of living units: Number of bedrooms 1 rix Character of soil to a depth of,3 feet: Water table depth SEPTIC TANK ❑ Tyne/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line r �i k 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."Contractors 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 cafi for all required inspectieC mplete drawing on reverse side. / Q Signed X � Title: Date: i.1 -3 ,�O FOR DEPARTMENT USE ONLY Application Accepted by Data 11 /87—Area Pit or Grout Inspection by rxw= Date Final Inspection by Date Additional Comments:%. ❑ Stk 466-8781 Lodi N9-3621 ❑ Manteca :823-7104 ❑Tracy Applicant- Return all copies to; Environmental Health Permit/Servicaa'1001 E. Hmmiton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED OY DATE PERMKT"NO. INFO C + EH 1428(REV.10/831 O O O S` 110' / C '7