87-4308 - Laserfiche WebLink

Home Browse Search

�p APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ( _ Telephone (209) 466-6* PERMIT EXPIRES-1-YEAR FROM DATE ISSUED - s(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 gulations of the San Joaquin Local Health District. f (jo a1.2 . % 0 l Job Address City Lot Size PM.— Owner's Name " L' /� f t �l ,Kddr-ees Phone Contractor Addressnse No. `� � ��Phon TYPE OF LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL FLO. PROP. LINE ,f' """' "`'FOUN'DATION ! """AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑-Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` { ❑ Domestic/Private El Gravel Pack L1 Tracy T 1-- - `y y ype of Casing M 4 Specifications ❑ Public El ^'1_ Deltta Depth of Grout Seal � � Type of Grout ❑ Irri ationt _A ,.-v.. ' Irrigation, ---Approx. Depth ❑ Eastern Surface-Seal-Installed- 4. by Repair Workf Done ❑ Type of Pump 3 # H.P. + State Work,Done_ lr i Well Destruction ❑ Well Diameter ? Sealing Material (top 501 {+ f- t Depth a Filler Material;( el w_50'► r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION A DESTRUCTION ❑ (No septic sysfe'rriSpermitjed if public sewer is 40""""'"'""""""' availablewithin=200feet:f f Installation will serve: Residence Cmero \ omial Other "` j � Number of'.iving units: Number of bedrooms �? �+ °i 4 ' ' Character-of soil to a depth of 3 feet: s x bl Water tae depth ' i 4 . SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 3 PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation—= - - ~- -Prbperty"L'ine oe x f oo- LEACHING LINE , No. & Length of lines Total length/size'- FILTER ength/sizeFILTER BED ? ❑ Distance to nearest Well [xyFoundation .2V—,/4'Property Line SEEPAGE PITS " , Number f _� SUMPS ❑ Distance to nearest: Well - Foundation . .� Por arty Line j r DISPOSAL PONDS ❑ ® �,�- i . 1 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 Healt!4District: 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-contractiAg signature certifies the following:"I certify that in the performance of the work for which this m perit iS issued,I shall employ perlons subject to workman's compensa- tion laws of California." The applittmust all fo - regwre pec ns. Complete drawing on reverse side. I y ^1 Signed X _ ills: Date:,- FOR DEPARTMENT ate:FOR,DEPARTMENT USE ONLY C} .4 Application Accepted b Date '� �"l Area 1 Pit or Grout Inspecti y 0 Date `'' Final I spectbri by Date? � Additional CorYimenYs'"'""" ❑ Stk 466-6781 ❑ Lodi369 362 t ❑ Manteca 823 7104 . El Tracy 835 6385 w Applicant- Return all copies to: Enviroh ental Health Permit/Services-1 601 E. Hazelton AveP.OeBox 2009, Stk., CA 95201 i _ �'` `"...•....v _ 'a. ,ay-..,,.FEE INFO AMOUNT-DUE- --^-AMOUNT'REMITTECI- CAS � RECEIVED BY DATA E PERMIT NO. a � + EH 13-24(REV EH 14.28 !