87-3768 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 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 t Local Health District. Job Address Uu 1 //' oWy`v City 421e- Lot Size PM Owner's Name /f/' acv I�6e� Address C;a&bafy ' 1%1.06 Phone r Contractor -C/ Y Address ZJ �%0 FW^ �l-�se`NoaO*f � Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ c PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ E 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 "a+ e Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F Public Cl Other El 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. State Work Done ' Well Destruction ❑ Well Diameter Sealing Material atop 50'1 ' - Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIRIADDITION DESTRUCTION l I INo septic system permitted it public sewer is j available within 200 feet.l Installation will serve: Residence Commercial_ Other , NumberAof living units: �_ Number of rooms Character of soil to a depth of 3 feet: Lo Water table depth SEPTIC TANK. C] Type/Mfg .Capacity No. Compartments PKG. TRI=ATMENT PLT. Cl Method of Disposal " Distance to nearest: Well Foundation Property Line { r LEACHING LINE I Fr--No. & Length of lines '"� �': ��- Total length/size L5 ` FILTER BED ❑ distance to nearest: Well 90 - Foundation�_._ Property Line SEEPAGE PITS f�tr Depth D�.�_ _ Size Number 1 SUMPS ❑ Distance to nearest: Well j Foundation &Ar Property Line y 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. 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, 1 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." I The applicant must call for al required inspections. Complete drawing on IN arse side. Signed X Title: - I 'C' Date: l6 j € FOR DEPARTMENT USE ONLY Appl atian Accepted by Date "� Area or�Grout Inspection by D Fi�l Inspection by lDate� (/ s ern -4- _ 2 L� -S c7 Additional Comments: Pro ❑ Stk 466-6781 ` ❑ Lodi '369-3621 0 Manteca 823-7104 ❑ Tracy 636-6365 f — el I Applicant - Return all copies to.-.Environmental Health Permit/Services 1601 E'Hazelton Ave., P.O. Box 2009, Stk., C 95201 �r FEE INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY [SATE PERMIT'NO. + EH 13-241REv.i/x51 /�� 04 EH 1428 / I