87-3012 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT F 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1Complete in Triplicate) P &IIIS 6D DAA-WI A) Application is hepeby made to the San Joaquin Local Health District fora permiu to construct and/or install them des =shed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rues and Regulations of the San Joaquin Local Health District. .fob Address a4 5. A) AA 9A E L City Lot Size 647 PM Owner's Name AA a sh A beg-m Address Phone A). A®c-4,cee� Contractor F"Y13 WDOD __Address — License No. 'iLYSY7rn Phone �b1'3g7J TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' LY DISPOSAL F PROP. LINE .FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONST ON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ anteca of Well Excavation Dia. of Well Casing 1-1M Domestic/Private ❑ Gravel Pack _ ❑ Tracy Type of Casing Specifications F Public w 171 Other to Depth of Grout Seal Type of Grout _ I i Irrigation _.Approx. De i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of H.P. FState Work Done_ Well Destruction a Diameter -Sealing Material-Itop 501 Depth Filler Material,lB_elow 501 _ TYPE OF SEPTIC WORK:- NEW INSTALLATION 1.1 RFPAIRIADDITION DESTRUCTION I I INo septic system permitted if public sewer is 3 " available within 200 feet.) t Installation will serve: ReResidence Commercial_ Other � ll O f �G �,4 �. - Number of living units: —/—! Number of bedrooms `�' 4 t 1 be&L a Character of soil to a depth of 3 feet: GL A rf ' Water table depth SEPTIC TANK 17'�'Type/Mfg Capacity No. Compartments 2— PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well AJI-4 Foundation 1 d Property Line f ?Ir T- , LEACHING LINE No. & Length of lines 1- 46 , t— '"`Total length/size S►X.Z FILTER BED ❑ Distance to nearest: Well AJ A Foundation 24' Property Line 4 SEEPAGE PITS c II Depth 12- 1 Size K p I Number SUMPS INr Distance to nearest: Well A41A Foundation, : Jdz Property Line DISPOSAL PONDS ❑ i r 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. s 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 must call for all required inspections Complete drawing on re arse side. Signed X w— Title: Date: 97 FOR DEPARTMENT USE ONLY i/h Application Accepted by4�LlDate Area ' Pit or Grout Inspection by ate Final Inspection by Date 7 Additional Comments: s R w - ❑ Stk 466-6781 ❑ Lodi 31-- 1 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE l INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE CK 0 PERMIT� + EH 13-241REV.tiasy EH 14-2a