87-3092 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a, n 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �/w PERMIT EXPIRES 1 YIEAR 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.J 1 Job Address _`7 ©-�LI"^ lJ r� _ City - Lot Size PM Owner's Name '� / 4j r A)Laddress Y- 0-.1-y- D�1 (.}� Phone tJ✓F y 40ATT��`Adddress 7 G r' 3 �-q Contractor J � J�o 1" �1E�License No��_ _Picone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL_ FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial" ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications N Fl Public j f7 Other. r.. ❑ Delta Depth of Grout Seal Type of Grout . I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump,- H-P. s State Work Done Well Dest uction ❑ Well Diameter Sealing Material (top 501 \f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION i I 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/Mfq___ 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,620 ❑ `Distance to nearest: Well Foundation Property Line s SEEPAGE P T� 1 l bepth Size Number SUMPS U Distance to nearest:.,_._.,.Well Foundation Property Line DISPOSAL PO DS ❑ _ L<` { F 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 regulhtions of the San Joaquin Lodal 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, I shall employ persons subject to workman's compensa- tion laws of California." ' The applicant t c II r all required inspections. Complete drawing on rev rssee 7side. Q� Signed X Title: �L1 LYJJNL ,/'1 Date: - O FOR DEPARTMENT USE ONLYv` ^ Application Accepted by Date _ Area ((� Pit or Grout Inspection by /q Date Final Inspection by Date Additional Comments: ` �! °L_` L �s7� c 70 ❑ Stk 466-6781 ❑ Lodi 369-3621 171 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERMIT'NO. INFO CA Aff ♦ EHiiZ4 3-24(REV.r/n sr r ` EH 14-2a �•.J `