87-1597 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT { ' 1601 E. HAZEL T ON AVE.,�STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I. :.I,.. � . 'a, (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 � ? ar �:•,: + t 1 c A ` City LLQt Si a PM s Owner's Nam %f Address �� 5 lJ Phone yI - I1-7 I ! a �]�1 / Contractor?-��? Address •O 6tv License No_3 ; roC� Phone t[]�-5�Q f f TYPE OF WELL/PUMP:; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r /w P:MP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .-.- �YAr� R DISTANCE TO Nf • EST:>S,I.EPTIC�TANK'. T SEWER LINES DISPOSAL FLD. PROP. LINE 1 ATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS _ I INTENDED USE TYPE OF WELL AREA-_CONSTRUCTION SPECIFICATIONS— ED PECIFICATIONS— EDIndustrial EJ Bottom ❑ Manteca II Excavation Dia. of Well Casing , ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ."type of-Casing =- Specifications ❑ Public ❑ Other []'.Delta Depth of Grout"Seal e of_Grout-. ❑ Irrigation -!L—Approx. Depth Cl,Eastern Surface Seal Installed-by Repair Work-Done.❑—Type of Pump H.P.,!- State Work Done 'Well Destruction c❑ Well Diameterw } � (c Sealing Material (top 50') f - +`� � »t Depth `FillerMaterial (Below 50')h' �y 11YPE QF-SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION O•r DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will_senre: Residence Commercial"' ^Other' Number of liv ng-units: .,Number of bedrooms Character of soil o a depth)of 3 feet: Water table depth ! t� SEPTIC TANK '4 T— No Type/Mfg r Capacity�OOO 4 1 . Compartments PKG. TREATMENT PLT.t.❑ !�° i Method of Dis osal J I y. 4w - ,7 AIS `^11 Distance to nearest: Well Q.. Foundation �y ��D � Property Line LEACHING-LINE_ Lf'�No. &•Length of lines �S >✓ —b� o7'SQ Total length/size fQ.S ILTER,BED ❑-.Disi#nYce to.nearest� Well .Foundation /O _'Property Line' SEEPAGE PITS ❑- Depth Size T Numbe�� w SUMPS ❑ :``Distance to nearest: Well Foundation rP46rty Line DISPOSAL PONDS ❑�I A` f e I hereby certify that I have prepared-this application and that the work will be done in accordance with San Joaquin county ordinances, state rules and regulations of the San Joaquin, Local Health.District. Home owner or licensed agents signature certifies theollowing: "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 rk for which this permit is i�'ed,Cl sF all employ persons subject to workman's compensa-` j tion laws of California." ! r The applicantnby inspections. Complete drawing on reverse side- Ti i e- Signed X Titler p `7 l Date: 2 0 �I i . i FOR DEPARTMENT U$E-ONLY Applliiccation ADate Area Pit a'r Grout Inspection by Date Final Inspection.b Date 'Additional Comments: ❑ Stk 466-6781 ❑ 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 INFO AMOUNT' DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. t EH13-24(REV.5/ns) - EH 14-28