87-2167 - Laserfiche WebLink

Home Browse Search

w-: cg r G �`' 7 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1, 1601 E. WAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 heroin 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 5? (� City Lot Size PM c ` I Owner's Name Address 46 Phone Contractor 814kv ol"A Address A-;� :' 4E' C License No.-V f� r Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L7 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF ❑ Industrial ❑ Open Bottom ❑ Manteca D' xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Type of Casing Specifications' (� {1 Public '"" `—❑ Ot F1 Delta '¢ Depth of Grout Seal 'Type of Grout I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type o(;Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 W t Depth --Filler Material (Below 50'.) TYPE OF SEPTIC WORK,' NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTIO (No-septic system permitted if public sewer is r i available within 200 feet.) \N Installation will serve: I 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 I. Distance to nearest: Well Foundation Property Line `" f LEACHING LINE L No. & Length of lines Total length/size J 1a FILTER BEP d Distance to rjearest: Well Foundation Property Line SEEPAGE PITS }l I Depth Size Number SUMPS 'Cl Distance to nearest: Well Foundation Property Line . DISPOSAL_ PONDS 'X17— ' -' ' 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, 1 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,l shall employ persons subject to workman's compensa- tion laws of California." The applicant m t call for all requ ired inspections. Complete drawing on reverse side. Signed X 7iNe: �� Date: FOR DEPARTMENT USE ONLY I Application Accepted by Date Area - Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: (/7/ tN gV''Al a7 ❑ 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 . 9 LIO,t,�-�G� ;jam (�1 � G 3�"�S� .rte' vr.,�-<J FEE AMOUNT DUE AMOUNT REMITTED. GK RECEIVED BY DATE PERMIT N0. \\\ INFO \ !� y �] C•�J` 13-24IREV.iiKs1 la C�(� % ` U N 'I 0 H t 4 4-28 4 V