87-2115 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT j SAN JOAaUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZELTON AVE., STOCKTON, CA j Telephone (209) 466-6781 , + 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.This application is P No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin.County Ordinance Local Health District. f,..v.. � /� j� �+ p.' } ^ L D f7 7 I it 1C 7 H ��l pi5c,y A1�O,l Jl Lot Size PM Job Address �y,, _ u W Owner's Name /SCO - Address Phone J Contractor $ �-S(S Address z9 !) ��^ � 4 icense No. ISO Phone t } YPE"OF WELL/PUMP:'"t NEW WELL ❑ WELL REPLACEMENT L) DESTRUGTIOR 11-T PUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E] DISPOSAL FLD. PROP. LINE r DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES i 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA y CONSTRUCTION,SPECIFICATIONS ❑ Industrial ❑ Open Bottom r❑ Manteca t Ria. of Well Excavation Dia. of Well Casing r "' ' Type of CasingSpecifications r ❑ Domestic/Pri ate ❑ Gravel Pack ❑.Tracy �, YP ❑ Public ❑`Other ❑ Delta'' Depth of Grout Seal Type of Grout %.ISurface Seal Installed by �4pprox. Depth ❑ Eastern .� r ❑ Irrigation I _ R. H p : -`w State Work Done' � Repair Work Done ❑ . Type of Pump r4 J"L' t, fi Well Destruction O, Well Diameter Sealing Material (top 50'1 r' x 'Depth _ Filler Material (Below-50'). M - - z. TYPE rlNSTALLATION LlREPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted.if public sewer is OF SEPTIC WORK: .. NEW available within 200 feet.) a Installation will.serve:•..Residence XCommercial� Other f Number of i%krJ units: "° Number of bedrooms a r Water table depth �. Character of soill to aldepth of 3 feet: SEPTIC TANK . a Type/Mfg Capacity No: Compartmerits " ` .r�. Method of Disposal PKG. TREATMENT PLT ❑ r I-ProertY Linew earest: Wll Foundation w` , LEACHING LINE/,,` Noy& Length of lines' GG Total length/size {�. . r i ; O Property Line FILTER BED [a;� Distanc0to nearest:` Well Foundation P rtY SEEPAGE PITS j. ;9� Depth Number d V Property Line Well Foundation J SUMPS ❑ Distance to nearest: DISPOSAL PONDS ❑`'+ I hereby certify that I have prepared this application and that'the work wlll,be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1 , r s 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, ! shall not employ any personn 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 is issued,I shall employ persons subject to workman's compensa tion laws of Calif o "-' ` The applicant usr all fo± all re ins ins. Complete drawing on reverse Sider L, Date: Signed X - - Title: OR DEPARTMENT USE ONLY + DaterL `" Area l I Application Accepted by } Date Pit or Grout Inspection by Date ` Final Inspectionby t r _ _ Additional Comments: . ❑ Stk 466-6781 ❑ Lodi 369-3621 ,❑.Manteca 823-7104 ❑ Tracy 835 6385- r Applicant- Return all copies to: Enavironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I 4Y CK RECEIVED BY DATE FEE PERMIT`NO. AMOUNT DUE AMOUNT REMITTED' CASH 1NF0 -7 d��s , `+EH1 3-N{REV. A s s1 EH 1428 - "'