87-3556 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 SEP 22 10,87 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Com lete'in Triplicate) ENVIROMENTAL HEALTH p PERMIT/SERVICES Application is fleteby"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 D%� /� r klllll/ f V City" Ca Y412PLot Size / 0 ,A-C PM Owner's Name ....__:54AV, I� J@I°tr 2r.r+ Address '8533 iff. fro/1 r'!e Phone 3 3 !33 3 Contractor Address -77��' G,'�i�P.x. l se No. 3 /5 hone 33479 130 TYPE OF WELOPUMP: �� NEW WELL WELL REPLACEMENT ❑ DESTRUCTION,❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ „DISTFINCE TO=NEAREST. SEIPTIC TANK -SEWER-1INES "DISPOSAL FLD.=/=- -PROP:'LINEb20-0— y - FOUNDATION / AGRICULTURE WELL _±� OTHER WELL--,--- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial pen Bottom ❑ Manteca Dia. of Well_Eiccavation .:.Dia:of Well Casing /? �Oomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing—� ".� Specifications 10q A, I. f'] Public f] O'�IIther 171Delta Depth of Grout Seal eO 'Type of Grout I I I Irrigation ' �P.Approx, Depth l I Eastern Surface Seal installed by 5,fTT.+s. Repair Work Done ❑ Typie of Pump' H.P. qsop Work Done _ (� I Weil Destruction ❑ Wefl Diameter.- �x Sealing Material atop 501I Depth Filler Material IBeI I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION I i iNo septic system permitted it public sewer is " - • .I1 available within 200 feet.) I installation"will serve: Resi8ence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth;of 3 feet: Water table depth ' SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well '� Foundation Property Line Y LEACHING LINE-J„, 'Cli;No.T&;Length of lines: - '�"t� Total length/size FILTER BED LJ Distance to nearest: Well ; Foundation Property Line SEEPAGE PITS �"_ I I epth Size"-- * �' _ Number SUMPS ;.. ❑ �Distance'-to nearest: r Well Foundation Property Line , i DISPOSAL PONDS ❑ �� t I hereby certify that I have prepared this applicatibh-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 agentjs 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 Califor ia." ill The applican�mll r6quir J inspec' amplete drawing on reverse side. Signed X isle: ._ --- Date: a /"�, /7 �-FOR DEPARTMENT-USE ONLY— Application Application Accepted by "Y Date Z-Z Area Pit or Grout Inspection bIY5 . Date Final Inspection by Date Additional Comments: , J� s* 466-6781 EJ Lod 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 -t piicant - Return all copies til: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY CK DATE PERMIT;NO. r EH 13-24(REV.1/n5Y \'J� EH 14-79