87-2810 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 3. 1 SAN JOAQUIN LOCAL HEALTH DISTRICT /y 1601 E. HAZELTON AVE, STOCKTON, CA / 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 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 19 1i�U e" ],�y7`' G 5C Zf�O Job Address g City � Tot Size 5o _. PM h L7f`A Owner's Name A lV l�a—i e k3 �14Ql�d�r _ �'�"� y�i ,�it C`- e'1 Phone ` Contractor S � Address License No'. Phone PE OF WELL/PUMP- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS7RU ION SPECIFICATIONS ❑ Industrial 13 Open Bottom Manteca Dia. of ell Excavation Dia. of Well Casing O Domestic/Private C3 Gravel Pack ❑ Tr T of Casing Specifications F1 Public L-1 Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth I I Eastern urface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Cl Well Diameter Sealing Material [top 50') Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i-1 DESTRUCTION I,Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other —" Number of living units: Number of bedrooms _ y� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity"'_ ; "-- ' No. Compartments PKG. TREATMENT PLT. 0 � 4 Method of Disposal Distance to nearest: Well Foundation 'F Property Line LEACHING LINE ❑ Na. &,Length of lines - � Tota! length/size FILTER BED ❑ Distance to nearest: Well t.. Foundation _ Property Line Ili SEEPAGE PITS 1 1 - Depth Size _ Number- SUMPS umber SUMPS L� Distance to nearest: Well" Foundation Property Line DISPOSAL PONDS ❑ " I hereby certify that l 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, 1 shall employ persons subject to workman's compensa- tion laws of California." 1 [ _ The applican must call for all required inspections. Complete drawing on reverse side. V \/I Signed.X �� 'l Gl'QCI _ Title: A^j ate: - 2_LJ ( FOR DEPARTMENT USE ONLY r7 Application Accepted by Date � Area /h Pit or Grout inspection by Date Final Inspection by Date Additional Comments: O� ' 1 r v f ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 v I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT E AMOUNT REMITTED) CASH CK RECEIVED BY DATE PERMIT'NO. '10+ EH13-241REV.I/x51 ♦ � EH 14-26 j O }