87-4012 - Laserfiche WebLink

Home Browse Search

N APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES '('YEAR 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. �/ Job Address 4 !p� d�Il}t C�r City N012p 0 Lot Size 50 -;L rU I PM -- Owner's NameAddress �7 tL'll Q !�-* Phone 7�y,7 Contractor G 1 C ct G-f Address� �� J oe fly /1d"ba License No. 5 7z� Phone ��✓�j� 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 El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public 1-3 Other f.-1 Delta Depth of Grout Seal Type of Grout I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 A TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIRIADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is J available within 200 feet.) Installation will serve: Residence� Commercial_ Other O Number of living units: _t__ Number o�.i bedrooms Q Character of soil to a depth of 3 feet: 0AP-d Water table depth ✓" , SEPTIC TANK LAY Type/Mfg a rue- Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ f Lf, � Method of DiNposal Distance to nearest: Well 50 Foundation f Property Line I I LEACHING LINE No. & Length of lines 961 Total length/size © +^ FILTER BED El' Distance to nearest: WellFoundation )0 l Property Line SEEPAGE PITSpt Size � Number SUMPS Cl Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ 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 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, I shalt 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 must call for ll regoired inspections. Complete drawing on reverse side. Signed X Title:49 G0ye „ Date: l 3- �:'7 FOR DEPARTMENT USE ONLY r Application Accepted by NJ& Date r Area Pit or Grout Inspection by Date Final Inspection by Date Q r Additional Comments: rM D ❑ Stk 466-6781 ❑ Lod -3621 C Manteca 7104 V A Tracy 836-6385 - ?7 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 05� gQ%GSjl L-P FEE �$6l INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT-NO. + EH CAIgH 13-241REV.I/A5) � EH 14-26 7a