87-1591 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SANJOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1; `�w'�► Telephone{209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) >� � ---s•� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desctibed.'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 elm 60 f _ City iIJl Lot Size S v piVl Owner's Name — 5. MA's ori " Address 6 Phone �6 � ��' tea. '4. .. Contractor UV^. Address D19.0._- l[�l�3D. License_No. �(a�Z Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION. ❑ i PUMP INSTALLATION p SYSTEM REPAIR ❑ O_THER ❑ . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOS PROP.+LIAIE .; FOUNDATION C AGRITU CULRE WELL ER WELL AS/ ELL i INTENDED USE TYPE OF WELL P,ROBLENI°AREA RUCTION SPECIFICATIONS,_; r Li Industrial: ❑ Open Bottom ❑'=Manta Dia. of Well Excavation + Dia. of Well-Casing a� ❑ Domestic/Private ❑ Gravel Pack z.i racy "' Type of Casing Specifications,# ❑ Public El Other C7 "Delta' Depth of Grout Seal Type of Grout� ❑ Irrigation pprox. Depth \0 EasterSurface Seal Installed by t i } Repair Work Done Type of Pump 3 H,P. _ State Work Dane Well Destruction ❑ Well Diameter }'` Sealing Mi' ateZ {p 50')'-------T r Depth I Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION [No septic systemiperniitted-if-public sewer is s. vailable_within 200 feet.) 1 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 `= S SEPTIC TAN KY, � �Type/Mfg p Capacity � No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: '' Well Foundation- ---- _--�---Property Line x" ; LEACHING LINE ❑ ' No. & Length of lines Total length/size e- FILTER BED' ❑ Distance to nearest: Well Foundation Property Line' SEEPAGE PITS KDepth Sjze Number k SUMPS. ,.r—D_,•"-Distance to nearest: Well - Foundation "Property Line A. •+F..- - y- DISPOSAL PONDS ❑ � � ;� ."'".�,�..,. x'-'^•.--.�'._--�.�..,.:=. _ —,�-*,-�---+ '•"`. f 1 hereby certify that"I F aii4 prepaaf6d this application-and'that iiia work will-Ee done in accordance with San Joaquin courityordinances, state laws, and I rules and regulations of the San Joaquin Local Health bistrict: f .r} 1 j 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-js issued,-I shall employ persons subject to workman's compensa- tion laws of California." ' �+r f R • t r:j. •t, The applicant mustcall for all required inspections. Complete drawing on reverse side. j Signed X Title: Date: /A I -FOR DEPARTMENT USE ONLY Application Accepted by Date — "� Area L/ Pit or Grout inspection Date Final Inspection by1 17 17 Date / Additional Comments: �a f�" OA l ,�y ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca .823-7104 {❑.Tracy 83&6385 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 CK H -RECEIVED BY DATE PERMIT'NO. + EH 24(REVr/ 5) EH 4-21 � f 3