87-3573 - Laserfiche WebLink

Home Browse Search

• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 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 Local Health District. " l x 3211 k Job Addresso,--7 i6e-uIGS City 11 + �, Lot Size �,4C PM Owner's Name Gl�Ors Address � la Phone i c r Contractor yj� �p` Address_ las-1 SNi7-A Ot License No. 3701'7X1 Phone 2600"Ff t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ h } DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` `_' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rte} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca --Dia. of Well Excavation Dia. of Well Casing l� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications , 'TAT JJJ F1 Public n Other Ll Delta Depth of Grout Seal Type of Grout' 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 (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i.l DESTRUCTION l I (No septic system permitted if public sewer is ` available within 200 feet.) ! Installation will serve: Residence Commercial—-Other Number of living units: _L_ Number.91pedrooms 3 Y1 r Character of soil to a depth of 3 feet: 214 A 90 r 1/ I Water table depth SEPTIC TANK Type/Mfg Com- 40- - 'Capacity No. Compartments PKG. TREATMENT PLT. [D Method of Disposal Distance to nearest: Well "T�'t Foundation 0_t Property Line vbo LEACHING LINE No. & Length of Iinek 0 Total length/size FILTER BED Distance to nearest: Well ��' Foundation .�_ Property Line 0 a 0 1 SEEPAGE_ PITS I'<Depth OJS Sij, `` Number SUMPS L-) Distance to nearest: Well V O � Foundation & I Property Line 6-40 f � 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. j 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all equired inspections. Complete drawing on reverse side. s, Signed Title: Date: 31'- 2JrIOF F� ' FORD PARTMENT USE ONLY Application Accepted by Date Area 4 Pi or Gout Inspection by ate nal Inspection by Dat . . � J Addltronal Comments: . Y ❑ Stk 11466-6781 ❑ Lodi 363-3621 EDManteca -7104 © Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 +. iFEE INFO-. ` MOUNT DUE AMOUNT REMITTED— CA49 SH RECEIVED BY DATE PERMIT-NO. ' .. + EH 13-24(REV., EH 14-28-