87-2578 - Laserfiche WebLink

Home Browse Search

f 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �Y(S�' PERMIT EXPIRES 1'YEAR FROM DATE ISSUED / I 7 a (Complete in Triplicate) 7(b X36 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 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 Joe in Local Health District. 6-Ade Over keg* 17Q0 fr f Job Address 12-10 U/!r ( f`Gi 6- Y,, [-Z- �� City red/, Lot Size PM Owner's Name`. f f v{ 0411I3A re f�°�� LB� KEW �/ �1� /}� Pone s Contractor V f7 Address V E A' lS !/f(ft Q/^ License No. Tr� �� Rhona TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ''.OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 II ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f-1 Public I� Other n Delta Depth of Grout Seal Type of Grout��HJoV I I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done L7 Type of Pump H,P. State Work"Don Well Destruction ❑ r Well Diameter Sealing Material Itop 50') C /`t AW tZ hAV I (,v l Depth � too t Filler Material (Below 50'1 �— TYPE OF SEP TIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION 1.1 DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence_ Commercial— Other G J Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS l I Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 shall not I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature' I 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." i The applicanVnust call for all red i s omplete drawing on reverse side. Signed 6r Title: Q f\ Date: Z /�� FOR IMI USE ONLY �f ��/j�s-7J'CA Application Accepted by G/� Date 7 3-a Area r p� Pit or Grout inspection by Date Final Inspection by A a 04 A A + PPA"V Z111 p Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3fi211 ❑ Manteca 823-7104 E3 Tracy 835-6385 Applicant Return all co les to: E noir n�r�al ealt Permit/Serol es 1601 E. Hwlton Ave„ P.O, BoX 2009, Sik CA01� , INFO AMOUNT DUE AMO^^U��NT REMITTED 5 rrrCK RECEIVED BY DATE r�, PERMIT'NO. + EH 1124 1REV.$/1`15]7•' -�S -,C� 1 i f ':i�7 ��s