87-1546 - Laserfiche WebLink

Home Browse Search

it is APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601}'E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 Ii 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.'TNs application is ..made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862-for well/pump and the Rules and Regulati6ns of the San Joaquin Local Health District. y Job Address city ✓ Lot Sized _PM -Owner's Name Scd I uce- Address P' 0 60)( 99G CR .1841 Phone -2 S f 12-0 Contractor 0 L Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION-�( PUMP INSTALLATION E) SYSTEM REPAIR [I OTHER 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ....I --._ROO P.,LINE--.-; F 0 U F4 D-A-T-1 0 N AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECtFICATIONS 2"Jindustrial El Open Bottom El Manteca Dia. of Well Excavation I I Dia. of Well Casing 0 Domestic/Private 0 Gravel Pack El Tracy Type of Casing P. I Specifications El Public ❑ Other 0 Delta Depth of Grout Seal Type of Grout Irrigation _�pprox. Depth E1.Eastern Surface Seal Installed by El Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction '%L Well Diameter Sealing Material (top 501 II Depth — Filler Material (Below 501 If TYPE OF SEPTIC WORK. N.:EW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION Ll (No septic system permitted if public sewer is 9 available within 200 feet.) Installation rve: Residence— Commercial Other Number of living units. Number of bedrooms Character of soil to a depth 3 e I nsta"at'on Residence nce 've Co Number in un Number of Commercial '91he, :droo.s o so e D 77 g Capacity um Character 'iv d pth f u-b' C aira e' f .1 to a 0 Water table depth SEPTIC TANK LJ Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. C1 11 Method of Disposal t t Distance to nearest: Well dation clation Property Line aNof lines hJsize � l LEACHING LINE 0 6o Length -&�engt FILTER BED 0 Distance to nearest: Well Foundation Pir-cithm:ty Line SEEPAGE PITS El Depth Size Number SUMPS C :.Distance to nearest: Well Foundation Property Line Y DISPOSAL PONDS 17 I hereby certify that I have prep'ared this application and that the work will be done in accordance with San Joaquin county ordinaRces, state iaw. -a,< 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 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-work-for-which-this permit 'issued,I shall employ persons subject to workman's compensa- tion laws of California." The'applicant must ,for all'required in tions�complete drawing on reverse side. z' CY-1 S i gtL';e;;d x 1 4- L17 X/11— I Title: -0-cc-P_ Date: . ---k DEPARTMENT E ONLY 2 Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Additional Comments- El Stk 466-6781 El Lodi 369-3621 C1 Manteca 823-7104 i Cl Trac' y 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 X;7-� FEE #AMOUNT CK DUE AMOUNT REMITTED RECEIVED BY: DATE INFO PERMIT'NO. + EH 1324 IREV. E) EH 14-28 Al