87-1263 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL,NEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 'Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) MA W 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. 549for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. `a V- tV f I Job Address �� 5' .v s.f Jy C L � 1 f City Lot Size PM ori A-L b f�Ej7,7— --owner's-Na ryFe v - - - _ Address Phone M Contractor ,.,_ �..—.� �. .--.... �_ - — -_ --- . �+.�'- �Ca�• 'C'/�-. -� .�„-�..-. —� r...,� ,,:,.,�-t„�. Address TYPE OF WELL/PUMP: License No. Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP 4NSTALLATION ❑ k 51'STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC T SEWER LINES ' 4' _ DISPOSAL FLD. PROP. TINE.=- c FQUNDATION ULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ❑ IndustrialOr- a ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Wel! Casing + ❑ Domestic/Private ❑ ack ❑ Trac I Y Type of Casing + Specifications } LJ Public F) Other ❑ Delta Depth of Grout Seal ❑ Irrigation ---Approx. Grout —Approx. Depth ❑ Eastern -Surface Seal�lnstalled by ` Repair Work Dane ❑ Type of Pump H p _. -State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is Installation will serve: ResidenceCommercial_ Otr , available within 200 feet.) her <_ Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg 1 s 1 F Capacity No. Compartments PKG. TREATMENT PLT. El4 ' Distance to nearest: Well Foundation Method of Disposal Property Line ". Y`\ ' LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED - ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Cl Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line i 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. 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 applica ust call for all req a inspecti S. Complete drawing on reverse side. Signed X {! Title: s✓ /• d .. Date: _ FOR DEPARTMENT USE ONLY Application Accepted by Date Area O Pit or Grout Inspection b ` Date Final Inspection by Dat Additional Comment.—� s � f o 1-15tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 O Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C x INFO RECEIVED' DATE PERMIT•NO. I ,