87-2030 - Laserfiche WebLink

Home Browse Search

�w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 ��r City "Lot Size r PM Owner's Na ! � ' Phone -33 L/`" Contractor=__e Address C �I; J qJ k" /cense No D Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ! i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ O Irrigation ____�Approx. Depth ❑ Eastern.J+-,, Surface Seal Installed by Repair Work Done ❑ Type iif`Pump; H.P'. State Work Done well Destruction ❑ Well Diameters Sealing Material (top 501 ' Depth Filler MaterialBlow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is O available within 200 feet.) Installation will serve: Residence— Commerciale Other. Number of living units: Number of bedrooms Character of soil to a depth of-3-feet-=� s Water table depth SEPTIC TANK O Type/Mfg I r Capacity No. Compartments 1 f - f- PKG. TREATMENTfP,LTn❑ 41r fi 3 } Method of Disposal a Distance to'nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well f�_'�Foundation „� / Property Line SEEPAGE PITS. '❑'�'Depth Size� 2 of'-fa 'Number SUMPS Distance to nearest: Well "'Foundation Property Line 10 i DISPOSAL PONDS .---❑ - - I I Lhereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 rules and regulations of the San Joaquin Local Health District. '` t 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." - Thea ant mus call for all re cti Complete drawi on reverse side. { J 171 Signed itle:�J�s�� Date: FOR DEPARTMENT USE ONLY �{ Application Accepted by 99 Data,-! la IF 7 Area or Grout Inspection by ate rFinal Inspection by Datea�-Ii , Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE` INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT''ND. + EH 13-24{REV.t/9 5Y * Q �fti• ��r7��tl EH 1429