87-4210 - Laserfiche WebLink

Home Browse Search

3wJ�5 - 1 APPLICATION FOR PERMIT "- �Z SAN JOAQUIN LOCAL HEALTH DISTRICT V 1601 E. HAZEL T ON AVE., STOCKTON, CA 1460 Telephone (209) 466-6781 � � PERMIT EXPIRES TYEAR 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 430 ��a�� City�':1�]� Lot Size '1 Y 1®® PM ' Owners Name -0>4w d. Address _ Phone Contractor � Address License No. Phone_ YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ THER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP. LINE FOUNDATION AGRICULTU L. OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLE A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private - ElGravel Pack ElTracy Type of Casing Specifications M Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _ 1 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ - Type of Pump H.P. State Work Done— I Well Destruction ' ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION Ll DESTRUCTI (No septic system permitted,if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �w_ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line -� SEEPAGE PITS I I Depth Size _ Number SUMPS Ll 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 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." The applicant m call fo�all required In ns. Complete drawing on reverse sidle.` / �h Signed X Title: w(,/d_� Date: f A,. r 9 t � � FOR DEPARTMENT-USE-ONLY- --- .. Application Accepted by _ Date Area 0 Pit or Grout Inspection byl rM /� DM_ Final Inspeec/tioon.byy Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED �K/H' RECEIVED BY // DATE l/ PERMIT*NO. FEE+ EH 13-24 1REV.I/x 51 EH 14-26 /tt�� (✓ l !� a_ 2 6-0 : y IV4 haNe, haz,,ni n5G 1_'V491