87-1950 - Laserfiche WebLink

Home Browse Search

"'E�� APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED , u . -. +• I: ' sty - .r (Complete in,Triplicate). _ ,. L`t• 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..r. ` V ]r r .y Job Address � lNGLRfe�.� _ - City ,;C�C�bN.Lot Size PM l Owner's Name A.) 61 PA �!"fAAE�✓— 'T Phone �--- 6.T- - 3 ?Contractor ! �Q.� +2Address , License No: 2'68 2 Phone d V3� TYPE OF WELL/PUMP:;"- NEW WELL ❑ WELL REPLACEMENT ❑ 'DESTRUCTION ❑ I El PUMP.INSTALLATION ❑ w: SYSTEM REPAIR ❑ OTHER ❑ 1 > DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL F PROP. LINE y FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C CTION SPECIFICATIQNS ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation' + Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack racy Type of Casingt Specifications IS ❑ Public j ❑ Other ❑ Delta. . . Depth of Grout Seal _ Type of Grout i C1 Irrigation ,._}�pprax_Depih ❑ Easterner Surface Seal Installed by Repair Work Don Type of Pump H.P; •. State Work Done, { Well Des Ion ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50'1 € f (f t TYPE OF SEPTIC WORK: NEW INSTALLATION C] REPAIR/ADDITION ❑ DESTRUCTION)( (No septic system permitted if public sewer is r -�*- - -- -^ -�--tr•-�- _ - vailaa ife within 200 feet.) l Installation will serve: Residence_ Commercial_ Other - I Number of living units: Number#of bedrooms t i Character of soil to a depth of 3 feet: ? I Water-table depth SEPTIC TANK { EJType/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT" ❑ J t 7 .ti Distance to nearest: We A 3 Foundation; ProperMethod of Disposal Property Line 41 ti r N LEACHING LINE Cl No. & Length of fines Total length/size ( r tea• P # FILTER BED ❑ Distance to nearest: Welles -Foundation Property Line I 1 J �t SEEPAGE PITS . ❑ Depth Y Size r E Number l T SUAAPS ..... ❑ Distance to nearest: Well Foundation Property Line r l 1 h Y DISPOSAL PONDS ❑ F 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 I rules and regulations of the San Joaquin Local Health District. . 'I f . I Horne owner or licbnsed 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p p y persons suject tpworkman's compensa- tion laws of California. I i _ The applicant m ' all for all required inspections. Complete drawing on r verse side. f L Signed Title: �✓ t'�Yt`lC / � Date• 1 FOR DEPARTMENT USE ONLY Application Accepted by Date Area r. : . i i 1 Pit or Grout Inspection b 4 x Date Final Inspection by a Date Additional-Comments: .D Stk `466 6781 \. O.Lodi.369-3621 ❑.Manteca 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 pUE- AMOUNT REMITTED" CASH 'RECEIVED BY` DATE` '" "PE01MIT'NO. i + 24EH 13- 1REV.t/H5J EH 1428 2— kl vA-1 a-1 ^1G( I -