87-2900 - Laserfiche WebLink

Home Browse Search

t APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT ..v.�.. 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR 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 SS 4 IStr4eR1 City Lot Size PM Owner's Name E�QLC_Zl 4 JR V Address _ L S �-J ► Phone Corltractor 'i1[114- A dress 31y� E4?1 U�t/ r License No. ��S Phone W&� 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARES C TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, o cavation Dia. of Well Casing ± D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public [1 Other C1.Delta Depth of Grout Seal Type of Grout . (�1 ` �, ,.; .r.» "1 I''I-liFiijl�iori __Ap�pTox:Depth�l"1 Eastern*""•'•'^- -Surface - - - -- - '-• ' - �`� i Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Welt Diameter . Sealing Material (top 50') 1 Depth Filler Material (Below 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION l (No septic system permitted if.pujseLwer�is available within 200 feet.1 i Installation will serve: Residence 1 Commercial_ Other . Number of living units: Numberr,of bedrooms Character of soil to a depth of 3 feet: Water table-depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.-TREATMENT P_L_T_._❑ f r Method of Disposal Distance to nearest: Well'w Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size •. FILTER BED ❑ Distance to nearest: Wel! Foundation?* Property Line SEEPAGE PITS 11 Depth Size = .ice- Number SUMPS Cl Distance to nearest: Well Foundation p 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. I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of-the work for which this permit issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring orsub contracting signature certifies the following: "I certify,that in the performance of the work for which this permit is issuedr`I shall empl pe ns subject•to workman's compensa- tion laws of California." "The applicant mt call for al Tuired. -inspections. C mplete dr wing on reverse side. �} Signed X ik wAn itle: Date: FOR DEPART M T USE ONLY -G t d ' Application Accepted by�" � Date Area Pit or Grout Inspection by Date 1 Final Inspection by Date —r Additional Comments: S S d"iQ1 6+ 1 ❑ Stk 466-6781 ❑ Lodi 36946521 ❑ Manteca 823-7104 ❑ Tracy 6385 '�- /j¢ do 7 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box UA UDZk x FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CAS r EH 13-24 IREV.t i x 5f _ �� 3S J—,7'3d EH 14-2e 44�� `' r