87-2632 - Laserfiche WebLink

Home Browse Search

R` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.; STOCKTON, CA RS(',E1V Telephone (209) 466-6781 PERMIT EXPIRES 9 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' dation made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Joaquin - I. Local Health District. ;' -�. L4 r } Job Address )Do2/I .L[/lC� r `.:. City A dWfl Lot Size PM Owner's Name t �� C "tP�4, _.Address _f{p��S 71�P.5. '941,0 Contractor 44 Address fp& icense No. . Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ L PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.109" PROP. LINE _. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �J INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d ❑ Industrial ❑ Open Boti_om Manteca Dia. of Well Excavation Dia. of Well Casing 16 t Domestic/Private V Gravel Pack ED Tracy Type of Casing PVC Specifications f` ❑ Public 17Other 1-1Delta Depth of Grout Seal fz Type of Gr ut f ❑ Irrigation 1---4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ FType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth IFiller Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence . Commercial— Other Number of living units: Numbier of bedrooms + Character of soil fo;a depth of 3 feet:l Water table depth SEPTIC TANK ❑ Type/Mff Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest,. .. Well Foundation Property Line + I � LEACHING LINE w ,F, ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: . Well Foundation Property Line SEEPAGE PITS ❑ Depth Size .Number SUMPS `❑ Distance to nearest: Well Foundation 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 such manner as to become subject to workman's compensation laws of California."Contractors 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." 1! The appli nt ust call for all requ inspections. Complete drawing on reverse side. Signed L4 Date: t J' FOR DEPARTMENT USE ONLY Application Accepted b = PP P Y Date `1 �� Area ea ILS Pit or Grout inspection by _ Date Final Inspection by Date � Additional Comments: ( of 7 7– S 50 1 br4 Ayo), f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-'71104s ❑ Tracy $35-6385 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 RECEIVED BY -.- DATE PERMIT`NO. + EH1324{REV.1/85S EH 14-28 . i