87-1663 - Laserfiche WebLink

Home Browse Search

r APPLICATION.FOR PERMIT )::7(�6 SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZELTON AVE.,,STOCKTON, CA N O W�L��u*n>za 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 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 , Job Address :4 .. City Lot.Size PM "Owner's Name _� �SS011��[] �► I ^+uFAddress t7 h L.Q a _ T Phone ��f Contractor Address TYPE OF WELL/PUMP: License No. Phone (� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \1N� w PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER '❑ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R ❑ Domestic/Private Dia. of Well Casing `ra ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Public ❑ Other . ❑ Delta Specifications I Depth of Grout Seal Type of Grout ❑ Irrigation _._,_Approx".Depth ❑ Eastern Surface Sea! Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') / Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Wo septic system permitted if public sewer is a Installation will serve: Residence available within 200 feet.) 1 i Commercial_ Other' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ' Water table depth' ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ F 4f Method of Disposal Distance to nearest: Well Foundation L: Property Line LEACHING LINE ❑ 'No. & Length of lines • FILTER BEDTotal length/size ❑ Distances to nearest: Well Foundation Property Line ' I! p SEEPAGE PITS ❑ Depth t "t •- ' p Size Number SUMPS O. Distance'to nearest: Well Foundation DISPOSAL PONDS (-IProperty Line - [ 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 ff 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 o certifies the following: "I certify r sub contracting signature that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's com nature tion laws of California." The applicant must call for all required,inspections. Complete drawing on reverse side. W ' y(r Signed X s `/ ,\ Title: �`a "—�7 Date: __ { R DEPARTMENT USE ONLY Application Accepted by 1. pt i Date rea U Pit or Grout Inspection byt Date Final Inspection by Date 271 k Additional Comments: t ❑ Stk 466-6781 LlLodi 369-3621 ❑ Manteca 823-7104. ❑ Tracy 835-6385 (' {, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I s f FEE AMOUNT DUE ; AMOUNT REMITTED C INFO SH' RECEIVED BY DATE PERMWNO. a EH 13-24 ME 1/95) � � �'� i+Z$J SSW ! EH F428 ,,f a ,yt gF47 I � .