87-1677 - Laserfiche WebLink

Home Browse Search

-Z Ilk APPLICATION FOR PERMIT SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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(:�3$o �l. i�-w'�9 City Lot Size+a � PM - t � - Owner's Name t ' ' Address �^ 7 3 Phone - — `30?7 r . ' Ca ,� 7l7 3RU96 34 -Slay f Contract C Address License No Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ p ,' PUMP INSTALLATION ❑ SYSTEM REPAIR'El OTHER ❑ v� DISTANCE TO NEARES SEPTIC TANK SEWER LINES €ISPOSAL FLD. PROP-LINE I F ION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Dia. of Well Excavation ~'i r e ^Dia. of Well Casing -� ❑ Domestic/Private El Gravel Pack ❑ Tracy �/v i(Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal , Type of Grout [ ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. r State Work Done— Well Destruction ❑ Well Diameter Sealing Material atop 50') t DepthFiller M al (Below 50'1• - ` �r^ J ! TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ADDITIO PT DESTRUCTION'l❑,'INo septic system"permitted if public sewer is' I '-'available within 200 feet) .#.�: ` Installation will serve: Residence_ Commercial Other Number of living units: Number of b rooms Character of soil to a depth of 3 feet: Water table depth ' c`" SEPTIC TANK ❑ Type/Mfw�L/15 (ems _ Capacity S2C90 No- Compartments` PKG. TREATMENT PLT. ❑ r 14�1 Method of Disposal ` } Distance to nearest: Well Foundation o Foundation Property,Line_ k LEA{CHING LINE No. & Length of lines Total length/.size t7< FILTER BED ❑ Distance to nearest: Well N: Foundation /O f Property Line #SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 : 1 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 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 s_ubiect to_workma_n's compensa- tion laws of California.. --- " � r 'The applicant ust call forA required inspections. Complete drawing on reverse side. � . t 4 Signed r Title: 1! , Date:�� C� I E FOR DEPARTMENT USE ONLY Application Accepted by L 0 ee U-R-ed Date '(� u✓ Area d� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 N Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. l + EH -$4iREV.1/R51 14 1 f, - 7 0-167 EH 14-28 V