87-1326 - Laserfiche WebLink

Home Browse Search

1 � APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICTS 1601 E. HAZEL T ON AVE., STOCKTON, CA t , Telephone (209) 466-6781 , l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t,w (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.. f Job Address +`, '��6 V Q a Te- City -' F • Lot Size PM Owner's Name-lO t4o P-t `7s3 C Address _ f �43 ej)rr Phone wContractor's NameAd P,6f_i H5 y ,(�L�� ense No. 311 Phone �� a TYPE,OF WALL/•P.Ij�AP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F UNDATION! AGRICULTURE WELL_ OTHER WELL ,.i PITS/SUMPS INTENDED USE YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom 'i —"-H--Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private El: ravel Pack `? •t ❑ Tracy j. Type of Casing ySpecifications ❑ Public Cl Other $ `'.,C7 Delta Depth of Grout Seal IType of Grout I Irrigation �pprox. Depth 0`Eastern Surface Seal Installed by— Ell L� 'p 5-1' N# H-P, State Work Done # Repair Work Done ❑ Tye of Pump Well Destruction ❑ Well Diameter y - - Sealing Material'ltop 501 .-��... # Depth 1 Filler Material (Below_501 l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ZADDITION�-❑,i DESTRUCTION (No-septic system permitted if public sewer is I t vailable within:200 feet.), Installation will serve: Residence X I Commercial— Other-- ±__�ij Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: :f I Water table depth a 4 - Capacity No. Compartments ' SEPTIC TANK .Type/Mfg -` ✓ •) Method of Disposal PKG. TREATMENT PLT. LlI Y i! Distance to nearest: Well *• Foundation Property Line LEACHING LINE El -No. & Length of lines Total length/size FILTER BED ❑ Distance to'nedrest: Well Foundation Property Line SEEPAGE PITS SDepth Size # Number SUMPS ❑I t}Distance to nearest:' Well i Foundation Property Line 4 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 LocaI Health District. t Home owner or licensed agents signature certifies the foowing: "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 sutiject'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,t shall employ persons subject to workman's compensa- tion laws of California." -------''r .j- -t - The applica must all for all r5-,eyyliced in ons. C late drawing on reverse side. Signed 1 Title, ` _ Date: r/ t � r FOR DEPARTMENT USE ONLY __ *' �,._ ..--.,_z-., -. .. lArea Application Accepted by Date Pit or Grout Inspectio y Date Final Inspection by Date Additional Comments: ''' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma ca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. INFO pIr f •+ EH 13-24 IREV.101831 -� EH 14-26 ------------