87-2735 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ts40" 1601 E. HAZELTON AVE., STOCKTON, CA lir; Telephone (209) 466-67$1 ✓ PERMIT EXPIRES 1,YEAR FROM DATE ISSUED ^r (Complete in Triplicate) '• Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is " made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1 Z ` City O Lot Size A 4r— pM .� Owner's Name >r i ddress _J3// . �.'V *-20 Phone C� r ' �� Contractor Address �; :,rr License No. � )S Z-♦'hone TYPE OF WELL/PU P: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El.� SYSTEM',RE_PAIR LiOTHER El„ . DISTANCE TO NEAfiEST:_SEPTIC TANK,�1�� SEWERLINES FLO. PROP. LINE s, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, ❑ Industrial 3 eKOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications � Ll EJOther ElDelta Depth of Grout Seal �� Type of Grout \\\ ❑ irrigation r ��pprox. Depth ED Eastern Surface Seal installed by Repair Work Done ❑ .Type of Pump H.P. � l n State Work Done Well Destruction ❑ Well Diameter Sealing Material itop 50'1V) Depth eP 90 - Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r <'X - available within 200 feet.) Installation will e: Residence_ Commercial— Other Number of living units: erof � r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK r ❑ Type/Mfg a acity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal II Distance to nearest: Well Foundation Pro Line p rfi r 9', * �, s LEACHING LINE ❑ No:.. Length of lines Total length/size— FILTER ength/site FILTER BED D Distanceto nearest: Well Foundation Property Line ,fit,. SEEPAGE PITS LJ Depth Si ems$ Number SUMPS 16istance-to nearest:--.--.Well ,� Foundation Property Line , .� DISPOSAL PONDS :q I hereby certify that I have prepared„this application and thd*e-work.Will be done in accordance with San Joaquin county ordinances, state laws, and ; rules and regulations of the San Joaquin Local.Health District,'-*N I`'`� t s .I Nome owner or licensed agent's signature Pe:tifiewthe following: "4 certify#hat in the performance of the work for which this permit is issued, I shall not employ any person Wiuch'manner'as to become subject To—Workman's�campensation laws of Califamia.”Contractor's hiring or sub contracting signature certifies the following: "!certify that In the performance 6f the work-for which tion laws of California." this permit is issued, I shall employ persons subject to workman's compensa- �3 . � i The applicant m c far al quired ' pectians. late drawing on reverse side. -�-+ p Signed �f e: f Data: l7 r A � FOR DEPARTMENT USE ONLY �� Application Accepted by Date o Area s !f *Pit Grout spectior®'n by Dai �� Final Inspection by i� i Date Additional Comments:_ O Stk 466 6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 J Applicant- Return all copies to: Environmental Health Permit/Servic6s 11601 E.'Hazelton Ave., P.O. Boim2009, Stk., CA 95201 i 1 : uA FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 4 + EH13-24(REV.1/a 5) C3(� ' �i L� EH 14-26 .. ..