87-1501 - Laserfiche WebLink

Home Browse Search

APPLICATION- FOR PERMIT t R SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone"(209) 466-6781 f, .r ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health Districf 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. ♦♦ i; Job Address Lot Size` PM 4 • f' Q�F v 4 �a. ._ w oL/ e- -fta ' Ad Owner's Namdress J1 'iy fL�' phone i\, i ' Contractor Jgls Address 4.�1. 1� License Nov2 Phone �.� TYPE OF WELL/PUMP: NEW WELL ; �a WELT: REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 7 - --� SEWER LINES V DISPOSAL FLD.f60 PROP. LINE FOUNDATION .1 AGRICULTURE AGRICULTURE WELL OTHER WELL PITS/SUMPSQ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom Manteca Dia. of Well Excavati"ons-- Dia. of Well Casing G1 y o . f L9'lrmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing._,,Gl�. f Specific9,ewer��i. ❑ Public ❑ Other ❑ Delta Depth of Grout Sea! Type of❑ irrigation _Approx_ Depth ❑ Eastern Surface Seal I;e Vnstalled by iRepair Work Done ❑ Type of Pump„ ewe H_P, State Work DoneWell Destruction ❑ Well DiameterSealing Material Itop 50'IDepthFiller Material (Below 50')TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION-❑ (No septic system permiavailable within 200 feetInstallation will serve: Residence_ Commercial Other Numberrof living units: Numberpf bedrooms Character of soil to a depth of 3 feet: Water table depthSEPTIC TANK ❑ Type/Mfg Capacit �'M y NoCompartmentsPKG. TREATMENT PLT. ❑ Method of DisposaDistance to nearest: Well ` Foundation Property Lines LEACHlNG`LINE ❑ No. & Length of lin Total length/size "'� FILTER BED ❑ Distance tb ' est:;`- ^Welter =.,Foundation ^Pro a Line Y''�. ' I: SEEPAGE PITS ❑ Depth I `"Size' f + Number rF SUMPS ❑ Distance to nearest: Well', Foundation. -ma=r - ` Property Line DISPOSAL'PONDS ❑ �f its 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,, -_ ti ; �-.--. "I certify that in the performance of the work for which th s.permit is issued, I shall not Home owner or licensed agent's signature certifies the following: , I 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:"l 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." ##, 5 f The applicant must call for all required'i n Complete drawing on reverse side. Signed X '�[ Title`h. �,-��` °� . Oate: FOR DEPARTMENT USE ONLY Application Accepted by - ' I Date Area Pit or Grout Inspection by Data Final Inspection b Date Additional Comments ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca-8,23:7104 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED FO b CASH, RECEIVED BY DATE fPERMIT'No. r t + EH 13-241REV.1/85l / 1�, �...�.. ` - � .. -. EH14-26 �, , !-3e „�` .,,� r;.