87-166 - Laserfiche WebLink

Home Browse Search

I a 3 + 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 (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. Job Address�s -, r City Lot Size PM Owner's Name ( Address Ca/(p zo, Phone LZ29- Q 05 0 Contract Address 0 Z� or 9`6 yf� 7(,�_.-(�License No..Ja��3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i c PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El 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 ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 1 C) Delta Depth of Grout Seal Type of Grout ElIrrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction El Well Diameter Sealing Material (top 501 Depth ( fler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI /ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_2�_ Commercial_ Other fir. Number of living units: _Z_ Number o b Broom 13 =l l Character of soil to a depth of 3 feet: �r :Water table"depth 0 4 SEPTIC TANK ❑ Type/Mfg Capacity eNo. Comparfr entsT PKG. TREATMENT PLT. ❑ ir Method of Disposaf Distance to nearest: Well FoundationPioperty Line LEACHING LINE ZK�No. & Length of lines o tTotal length/size FILTER BED ❑ Distance to nearest: Well JPO Foundation Property Line /01 X SEEPAGE PITS Zr"Depth r9A Size_-_ Number ' ��-tit �-i' �'' r r � - SUMPS ❑ Distance to nearest: Well'" UQ/'` -Foundation / Property Line k: .i DISPOSAL PONDS ❑ ' e*� - - - .- - _ y,r�� 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. '� r Home owner or licensed agent's signature certifies.the.following:T"I certify'that in the performance of the work for which this permit is issued, I shall not employ any person in such'manne►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- o-`.- - --- -- The;applican t,Gall f II'r wired Inspections. Complete drawing on reverse side. f r ' ! `7 y Signed Title: __ �,/- Date: (D �/ I FOR DEPARTMENT USE ONLY Application Accepted byDate Area 7- Pit or Grout Inspection by Date Final Inspection by Date 7 Additional Comments: ❑ Stk 466-6761 , Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE K i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EM 3-24`REV.1/e 57 EH 13-24 ` - �L r� 7 67ASe6 i