87-2780 - Laserfiche WebLink

Home Browse Search

,V %C APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA h jru-„ Telephone {209} 466-6781 �1 4 7 PERMIT EXPiRESA YEAR FROM DATE ISSUED kjz - (Complete in Triplicate) ul h-- ? , 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 h 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. r%cl .. Job Address �- f✓ City s fav Lot Size PM . f W �, wner's Name Q7�9'I _ i� � Address rn r4- 7Nj� Phone A<17Jt -X35215 .01 Cdntractor G Address License No. Phone "d TYPE OF WELL/PUMP; NEW WELL ❑ WELL FTEPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal P Type of Grout ❑ Irrigation --Approx. Depth ❑ 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 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION iNo septic system permitted 9 public sewer is t J7 -available within 200 feet./ . Installation will serve: Residence— Commercial— Other ;- -•--� Number of living units: Number jof ro Character of soil to a depth of 3 feet: ' Water table depth e SEPTIC TANK ❑ Type/Mfg pa-i f No. Compartments PKG. TREATMENT PLT. ❑ Mit i aY haVP e f Method of Disposal;' - - �-recd �€��r�i�t � Distance to ner-k bIl au dation Property Line r LEACHING LINE ❑ No. & Length o gn riuirorirni- .i:?j -A (;6, fi.ft_ff tal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS El Depth Size �I .Numbers _ SUMPS ❑ Distance to nearest: WellFoundations rProperty Line DISPOSAL PONDS ❑ f i hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and 1 rules and regulations of the San Joaquin Local Health District. 7 T 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 oi'sub=contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ 6' tion laws of C ifornia.'. P Y Persons subject to workman's compensa- � 1 N The applican ust call for all required inspections. Complete drawingoneverse side. + r 4 Signed Title: Date: ' t FOR DEPARTMENT USE ONLY Z 2 Applic?ionAccepted by Date r �� Area �Y Pit or Grout Inspection GDate Final Inspection by Date Additional Comments: 3 O ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:, CA.;:3 I FEE ' INFO AMOUNT DUE AMOUNT REMITTED ,GASH RECEIVED BY DATE PERMIT•NO. �e V .'{4{REV.1/13 5) K;��