87-3086 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �r SAN JOAQUIN LOCAL HEALTH DISTRICT / �p 1601 E. HAZELTON AVE, STOCKTON, CA "�` Telephone (209) 466-6781 u��wit t4l '""7 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 10 a" (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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. y Job Address 4! Sf City MO-0411 Lot Size PIVI Owner's Name /� 00, J n 0—kUddress Phone Contractors//a Ah er (_,0n S I: Address_2hr r�e Y-4 License No.jf6166 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS YA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS di ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I1 Public 0 Other ❑ Delta Depth of Grout Seal Type of Grout -- I i irrigation _-____Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. a State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material [Below 50') p TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ] DESTRUCTION (No septic system permitted if public sewer is } T available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of-fines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number r SUMPS Cl Distance to nearest: Well Foundation 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, ane 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 C r .11 The applicant all required inspections. Complete drawing on reverse side. Signed Title:_A04 Pr- - Date: FOR DEPARTMENT USE ONLY Application Accepted by Date l 7 Area r _ Pit or Grout Inspection by Date Final Inspection by !� Date VV�� Additional Comments: A'z 4"- 0 Z❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca H2 -71 Tracy 835-6385 a�y 4„x— c Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax Stk., CA 95201 FEE INFO AMOUNT DUE A UN REMIT ED I (`ASH RECEIVED BY DATE PERMIT'NO. ♦ EH1 3-24 IftEY,v i H 51 U EH 14-26 VVV