87-4219 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1601 E. HAZELTON AVE., STOCKTON, CA M-7Telephone (209) 466-6781 C' 1 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED NTAL HEALTH (Complete in Triplicate) ENFIEMY/SERVICES 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 Diisstrict. � � 4 Job Address J'T City A Lot Size PM Owner's NameI�L AA4 1fA1( Address /�it?^� hone — Z 00 1/ i Contractor Address -rise No,774-9/ Phone e? 7- TYPE OF WELL/PUMP: N WELL �0- WELL REPLACEMENTIO DESTRUCTION ❑ PUMP INSTALLATI N Ltl� SYSTE EPAI ❑ HER ❑ �1 _-DISTANCE TO NEAREST: SEPTIC-TANK A1SEWER LINES 1 _e_ DISPOSAL FLDROP._LINEr FOUNDATION AGRICULTURE WELL ,�_OTHER WELL PITS/SUMPS _ INTENDED USE TYP OF WELL PROBLEM AREA CONSTR CTION SPECIFICATIONS ❑industrial Open Bottom ❑ Manteca Dia. of Well Excava ion Dia. of Well Casing r ❑'.Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Pu n Other Cl Delta Depth of Grout Seal Type of Grout,,-. _ 1 rrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ Re air Work Done ❑ .Type of Pump 7d��H.P. a6i State Work Done_ Will Destruction ❑ We11,Diameter �-� Sealing Material (top 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEWANSTALLATION I] REPAIR/ADDITION 1 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) l5stallation 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 ❑ Type/Mfg 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 SEEPAGE PITS-- _ I I Depth _ Size Number SUMPS [_l Distance to nearest: - -Welt foundation�- -�-�.-^--P►opeti+t*-tine �= DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will,be done in-accordance with San Joaglin county ordinanc@ state lavvsd 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 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 t call fo7 . r e��ds ctions, Complete drawing on r se side f/� �/ Signed X tel/ Title: -- ' Date: / d'r (J OR DEPARTMENT USE ONLY I u ��t�,,�,S/may _ Application Accepted by 4 Date �✓� Area Pit or Grout Inspection by Date Final Inspection by / Date 2 e� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE A UNT REMITTED CASH RECEIVED BY /f/ DATE PERMIT NO. + EH13-24(REV.r i n 5) � /�O EH 14-28Qn