87-3909 - Laserfiche WebLink

Home Browse Search

` k=APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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.: Job Address 1 7S 1F Y 1 Size r a n f?d.<�_` � Cix� tyL+g�_02 Lot r7�. PM Owner's Name I!t �i �l �i4 !!�� Address �� / ►1,fr(� L:j?f2C �/�..r Phone 4 10 tt 1� `` ��33 1 Contractor W006' (,f1 L 11 �ge �r� 4C�ddress /1� �1 iMMr, /7AZ License No..:Vlty/6 Phone7451-4 6 -7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ g DISTANCE TO NEAREST: SEPTIC TANK 1,5x— SEWER LINES 156 1 DISPOSAL FLD. PROP. LINE hyo, FOUNDATION AGRICULTURE WELL OTHER WELLALO-0-1 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial X Open Bottom ❑ Manteca Dia. of Well Excavation i1 Dia. of Well Casing IF+ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__JI9 A _ Specifications 4 SA C_r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 15� Type of Grout-45qA)d't' 4%+'+ro'U ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by bad 5 W�l Z OR, 1 l 1 4-1:!1, r \t Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material(top 501) f `� k Depth Filler Material {Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is. �= available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 performancelof the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." t - Theapplicant must call for all r�_aiired iinnsq3ctions. Complete drawing on reverse side. Signed :W L cp,- f Title: L' /V f fZA G 7 6' /Q,2 7 Date: FOR EPARZMENT USE ONLY Application Accepted by Date v 0 A, V f Area -� Pit or Grout Inspection by Date L_3Final Inspection by Date (� Additional Comments: aw ❑ Stk 466-6781 ❑ odi 369-3621 Manteca 823-71 ❑ Tracy Applicant-Return all copies to: Environmental Health Permit/Servic s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 3-24 EH 1428(REV.E/851 1 ✓, �/ (J L7 `3 . t 1 �J ' F