87-140 - Laserfiche WebLink

Home Browse Search

h� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. .�r + Job Address 1�r�L Ui' . ! l r 1AJ�' City Lot Size � PM Owner's Na-of__A� �l�'.) Address Phone Contractor�� --�f-�'fly —Address cik—License No. hone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ " OTHER ❑ 3 i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDI5POSAL-FL-D: —_- PROP. LINE * � :.FOUNQATION ' ' AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED'USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS:`_ r r s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _Specifications E ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout t ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth # Filler Material (Below 5111 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑. DESTRUCTION ❑ (No septic system permitted if public seweris available within 200 feet.) Installation will serve: R sidence r Commercial Other Number of living units: Numb of bedrooms G Character of soil to a depth of 3 feet: �� y_l �� Water table depth j SEPTIC TANK �' Type/Mfg�k� CapacityASQ� No. Compartments f PKG. TREATMENT PLT. ❑ 1 I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ! 'No. & Length of lines — Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS ❑ Depth Size Number 4. s SUMPS ❑ Distance to nearest:f• Well Foundation Property Line I DISPOSAL PONDS . . F-1. { 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 F employ a pe in such manner as to become to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies'i a follow) g:"!certify that in th ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws f Calffor 'a." ,t I l The applicI nt m t II f -required inspections. Complete drawing on reverse side. f r t �[ Signed' Y _. _ ry Title� � Y� _ _Date: `r-3d FO DEPARTMENT USE ONLY t 1 Application Accepted by V Date Area © `y 1 I Pit or Grout Inspection by Date Final Inspection by Date/rt I �,�r L Additional Comments: if f � �/ �` / . S /I I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca-` 823-7104 , ❑ Tracy Bro4lfM 1iI � 'i c�. Applicant- Returmall cbpies'to.- En`vi'ronymental Health Permit/Services 160""E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 # � I I INF AMOUNT DUE AMOUNT REMITTED C SH RE IVED BY D TE - 7�P"ERMIT'NO. i EH114-28 3-24 EH (REV.5/x51 1