87-2216 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 IJ U N 4 1987 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROM�NTAL HEALTH Complete in Triplicate) FERMI1fSERV"c-S 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 Sari,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. i Job Address City Sl0C-XCA-0^ Lot Size PM i f _ n IJo✓si+ov► Owner's Name E7s?�� U•Z.A• Addr4ss �� 9it s7 Ne. cl,,&-c- M vA. -rx Phone 1�1r�t't�,�ca.GtT�.C. ��i � 1•f�i .�. ?Ihi� l rc7_ur22otn. Contractor Address n1P_- �rcense No hone /-2 3 TYPE OF WELL/PUMP: NEW WELLpg,, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE • E FOUNDATION •7� �,ry AGRICULTURE WELL ��p�OTHER WELL PITS/SUMPS ,F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑,Open Bottom ❑ Manteca Dia. of Well Excavation 70 pia. of Well Casing ` eat t-% ' ❑ Domestic/Private I Gravel Pack ❑ Tracy Type of Casing ( NIC. Specifications k ❑ Public ❑ Other ❑ Delta Depth of Grout SealI Type of Grout �' 4-C, Ll � Irrigation 40 Approx. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump W.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 I Depth Filler 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: iF Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 i 1 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, an 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 no k employ any person in such manner as to become subject to workman's compensation laws of California."Contractoes hiring or sub-contracting signature` certifies the following:"I cert 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." 11 - The applicant must cal for all required insctions. C plate drawing on reverse side. r' I i Signed /" Title: Date: 7 &7 Il F T O Application Accepted bv ate !�� "`Area ,�qf kPit or Grout Inspe ion A Date `� '"�� Final Inspection by �- Date p ` c Additional Cam nts: G Stk 466 6781 ❑ Lei 369-3611 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95--1 FEE INFO AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT NO. � t i + GH 13-24 EN 1428(REV.i i 8 5) *% (0 C5,2> [�