87-2336 - Laserfiche WebLink

Home Browse Search

II. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL,HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA II -Telephone (209) 466-6781 b PERMIT EXPIRES`1 YEAR FROM DATE ISSUED ` i (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 Joauin 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 V-C--- ti`..i< City' S -17V ll-'/-Lot Size ' PM Owner's Name iaddress -- hone .114 Contractor S Address CS L� v-' cense W2 5793 V 5 Phone TYPE OF WELL/PUMP: II: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUM, INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE fv FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ( n INTENDED USE YP�E-OF WELL---PROBLEM-A_REA CONSTRUCTION SPECIFICATIONS ❑ Industrial /1� 0peri*Bottom r, g I �❑ Manteca' Dia, of Well Excavation Dia. of Well Casing � ❑ Domestic/Private ❑ Gravel Pack ` ❑ Tracy Type of Casing Specifications ❑ Public ❑Z41h "r c,� ❑ Delta I Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ EasternSula'ce.Seal Installed by Repair Work Done ElType of Pump H.PiState Work Done Well Destruction ❑ Well Diameter 5ea6ing Material (top�50) Depths ` *' FillerlWterii_F(Below TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPA19 ADDIT10N Ly DESTRUCTION ❑ (No septic system permitted if public sewer is g l available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: _ �M' Number of bedrooms AJr F Character of soil to a depth of�3 feet: `f ° 'Water table depth SEPTIC TANK 9 Tyipe/Mfg �/� �.41L/.11,�ir1'� � Capacity /'Z 420 No. Compartments PKG. TREATMENT PLT. ❑ �� r Method of Disposal Distance to nearest: Well ,I Foundation k Z 40 Property Line l LEACHING LINE & Length of lines 1�. s g + -; Total len thlsize FILTER BED ❑ Distance to nearest: WeII f Foundation Property Line SEEPAGE PITS 4?� Uepth4Size'=-1 �` Number 2 SUMPS ❑ Distance to nearest: WeII Foundation /C> Property.Line. 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, I shall not employ any person in suchmanner 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 all eq uired inspectio . Complete drawing on reverse side. ; i Signed X _ o ` _� Title: Date: �r FOR DEPARTMENT USE ONLY Application p Y)station Acce ted b II Date �07 Area 42� § Pit or Grout Inspection by ` Date Final Inspection In Date Additional Comments: / 4 r r FIt 84, ❑ Stk 466-6781 ❑ Lodi 1369-3621 ❑ Manteca 823-7104 ❑ Tracy 831-6385 Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE F,AMOUNTDUE AMOUNT REMITTED- CK* RECEIVED BY DATE PERMIT`NO. INFO 1,, CASH + EH43-24 MEV.t/e 51 � J�, EH 14-26