87-2360 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j} r 1601 E. HAZEL T ON AVE., STOCKTON, CA `1 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 forpwell/pump and the Rules and Regulations of the San Joaquin Local Health District. pQQ`Z H w16�$t' C141 e A;c.=(tl_ ,3.¢Q�A � Job Address C/ ISS IV A) /l � City 7 rZ Lot Size PM Owner's Name 9 A I-A Address s� Phone Contractor /Q r Zz >`-vLL(-;1R_ Address r�do f y� /t�7%t+/�. License No.;/S ��_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER ❑ , DISTANCE TO EST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 C ION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR CONSTRUCTION SPECIFICATIONS 1' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o vation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Qf=rout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Donee ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 `)1 TYPE OF SEPTIC WORK: NEW INSTALLATION yREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) V� Installation will serve: Residence L Commercial_ Other Number of living units: +_ Number of bedrooms _ Character of soil to a depth of 3 feet: �Q�d'f3�- Water table depth SEPTIC TANK Type/Mfg p �� Capacity. No. Compartments PKG. TREATMENT PLT. ❑ �— �-- Method of Disposal Distance to nearest: well AZ =100�— Foundation A0 Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation 1,4—L fT- Property Line (� SEEPAGE PITS ❑ Depth OO F rSize Number _ SUMPS ❑ Distance to nearest: Well 0 r'T Foundation Property Line g 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."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 oilrequiredinspections. Complete drawing on reverse side. �s C Signed X e 1W. `► UL�-G ��- •Title: G '�'� Date: 'e"e— o �' FOR DEPAR MENT USE ONLY Application Accepted by Dated Area Pit or Grout Inspection by Date Final Inspection by Date ^�= � 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 AMOUNT REMITTED CASH RECEIVED BY -- DATE PERMIT NO. + EH 13-24(REV.t/65) ?/. // /7 � EH 144-28 (/ --T