87-1157 - Laserfiche WebLink

Home Browse Search

;3 31 , APPLICATION FOR PERMIT ' ` -f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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.: JI I Job Address — ��' SlAlL-L .41p— City x Lot Size d-S-X 3J3 - PM Owner's Name _ bEi � �/ft�s Address — Phone Contractor = &1bZ)" 'Address AA 4-I A License No.4j- 74__Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS. — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -- 11 ' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V .I El Public LJOther [71Delta t$I- Depth of Grout Seal I Type of Grout ❑ irrigation --Approx. Depth ❑ Eastern f, �;Surface Seal Installed by- Repair y Repair Work Done ❑ Type of Pump ! H.P.?' " ' I State Work Done Well Destruction 171Well Diameter Sealing Materia{ (top 50') Depth ! Filler-Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ r DESTRUCTION (N .septic system permitted if public sewer is ,/ �f available within 200 feet./ Installation will serve: Residence, Commercial_ Other - Number.,df living`:units:"- �y-Number of(bedrooms Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK ❑ Type/Mfg 57 f Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ !. Method of bi'sposal Distance to nearest: WellFoundation Property Line d : g LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS ❑ Depth I I Size Number N -SUMPS �{"Cl {Distance to,nearest Well Foundation Property Line i 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. `J, I I Home owner or licensed agent'srsignature certifies the following: "I certify that in the.performance of the work for which this permit is issued, I shall not employ any persori 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,l shall employ persons subject to workman's compensa- tion laws of California." r ! ti The applicant must.call ar all required inspections. Complete drawing on reverse side. l i Signed M1 f Title: ! _.Date: FOR DEPARTMENT USE ONLY i Application Accepted by Date Area Q f Pit or Grout Inspection by n ,'I Date Final Inspection by Date Additional Comments: '❑ Stk 466-6781 ❑ Lodi 359-3621 VID Manteca 823-7104 ❑ Tracy 835-6M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., t A 95201 FEE AMOUNT DUE �AIVIDUNT REMITTED CKjV H RECEIVED BY DATE PERMIT'NO. INFO 1