87-4134 - Laserfiche WebLink

Home Browse Search

f - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 • PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 escribed. 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. Job Address 1 ` W _ City of Size PM i Owner's Name `1L �#GVj :72-0 � ' Q �j R*� 3 3 3 /'a 2` Address 0 O f F�fr t _ Phon rd Contractor �.� Address License No. � Phone TYPE OF WELL/PUMP:_ ANEW WELL ❑ a g� _WELL REPLACEMENT p DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L❑ .� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_ FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS �Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E) Industrial ❑ Open Bottom ❑ Manteca Dia.bf.Well.Excavation Dia. of Well Casings ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing?! Specifications Fl Public F1 Other 4 ❑ Delta Depth of Grout Sea! ! Type of,Grout I I lrrigaripn _--Approx.'Depth € I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. - t State Work pone_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth IFiller Material IBelow 50') TYPE OF SEPTIC WORK: NEW INST-Ak-LAT-"N-'-:' AEPA" ADDITION-/ 1-DESTRUCTION` "INo Septic-system permitted if public sewer is "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 16 nearest: Well FoundationProperty Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth ' � Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS C } F ! hereby certify that I have prepared this application andthat-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. 4,; , 1 that in the performance of the work for which this�permjt is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify employ any person in such manner as to become subjectto workman's compensation laws of Californian" 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 Calif rnia." # r ( t J The applicant m call for a ulnad inspections.pections. Complete drawing on reversesidaJ. . Signed X € ' Title: C/ .. Date: _ R Or MENT.jUSE ONLY.- Applicati ccepted by AA Ir ` z Data / Area t Pit or Grout inspection by Date Final Inspection byS � Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ---0 Tracy'835-6385 l' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1V" FEE INFO AMOUNT DUE i AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. * (REV.t i is 5) EH 10-2e L