87-3618 (2) - Laserfiche WebLink

Home Browse Search

z APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 5 . 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED F —,)Z (Complete in Triplicate) �w d►YuJ[[�� ►.•�rJ -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 Joaquin Local Health District. 2 Job Address q 4 City Lot Size Owner's Name u T` ' ' B0t7h#Address �1 1 Phone Contractor�" "✓. � Address License No.^ Phone_ TYPE OF WELL/PUMP: r NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK --SEWER LINES �� DISPOSAL FLO. PROP. LINE FOUNDATION AG ULTURE WELL OTHER WELL PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEM ARE 0 STRUCTION SPECIFICATIONS •a ❑ Industrial 0 Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing Q Domestic/Private 1=1 Gravel Pack— O Tracy Typ of Casing Specifications I"1 Public L1 Other C] to Depth of,Grrout Seal Type of Grout I I Irrigation '%_Approx. Depth I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done } Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW-INSTALLATION IJ REPAIR/ADDITION I 1 DESTRUCTIOo septic system permitted if public sewer is v INailablee within 240 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. F1 u� Method of Disposal Distance to nearest: Well Foundation Property Line C iE e V LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I 1 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J - 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, ander 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 notes employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature tp 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 ail required inspections. Complete drawing on reverse side, igned XTitle: Date: OR ARTMENT USE ONLY . Application Accepted byt�A. h„n C1 -.0 Date Araa . ��. Pit or G out Ins ctio Date Final Inspection bow , Date Additional Comments: 2 7 0 ` ❑ Stk 466-6781 ❑ Lodi 169-21651 C) Ma teca 823-71 ❑ Tra y -6385 J -4 �� 3 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelt Ave , P.O. �ox 2009, Silk., CA 95201 /CJ0 �wz.�z p v�.c 6" o fl- &A-C--Z j u C.G Cd INFO FEE AMOUNT DUE AMOUNT REMITTED CAS RE r� + EH 1 [� -241REV.iiKsY JC7 C)O r f� -I � EH 1428 tr