87-3219 - Laserfiche WebLink

Home Browse Search

r �1r APPLICATION FOR PERMIT f' 1 " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 "—PERMIT EXPIRES TYEAR 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., P75 Job Address Z7"% � City /lASn/2k3P Lot Size/& ezl:m --M Owner's Name. ;�dezT__tZ� Q11��A Address � � G2� Phone i i / �p� f 'Contractor ✓� Z4. ''V Address d � �vk%-License No. Phone - TYPE 0'FWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f 4 1. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE ;:TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0'Industrial ❑ Open Bottom ❑ Manteca- _..Dia. of±Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing ' Specifications ❑ Public CI Other LI Delta Depth of Grout Seal Type of Grout _ I I IrriWation --,Approx. Depth l I Eastern Surface Seal Installed by _ flepair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') y Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION 1,1 DESTRUCTION VNo septic system permitted if public sewer is available within 200 feet.) -Installation will serve: Residencetl'' Commercial_ Other Nurpber of living units: Number of bedrooms Character'of soil to a depth,of'3 feet: r j '`{+ Water table depth SEPTIC TANK CrJ Type/Mfg 1Capacity^� No. Compartments Ad TREATMENT PLT. ❑ „'' �•, � a ` Method of Disposal Distance to nearest: Well - Foundation` -- + Property Line a t+ % -LEACHING LINE ' ❑ No. & Length of lines Total length%size :+ FILTER,,RED ❑ Distance to nearest. ¢ WelF, Foundation Property Line t SEEPAGE PITS 11 Depth Size _ Number I SAkiMPSLl Distance to nearest-, Well Foundation Property Line x 6IS%0SAL 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 SaA Joaquin Local Health District. i.r 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 ,eelnploy any person in`such manneras,to become'subject to workman's compensation laws of California.” Contractor's hiring or sub-contracting signature '&hifies 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 I5,ws I CalifoPnia." I ry' The applicant must call for all equirao inspections. Complete drawing on reverse side. Signed�Xre ` Title: Date: j ^ ; FOR DEPARTMENT USE ONLY ,tet" '44cetion Accepted�by` {/-7-21 Date / Area IF 'Pit or C,rout Inspection'by r ` �� }-Date Fi I Ins tion b Dat � 7 + Additional'rCorDmiints Y t /pw ' � ;11 6e, a Tracy A'pjflic nt etu�n all Best o{: Environmental'He❑althanieca Permit/Serycels 1601 E.❑Ha elt n 835-6385 3Ave.,P.O. Box,2W9,.Stk., CA.95201 'A h *' INF© '' AMOUNT DUE AMOUNT MITTED CASH RECEIVED BY D TE PERMIT NO. • �t axe + Et1�,1l-24(REv.+i,nsl 1$35 ® lJ �r �� -: EH1142e - a