87-59 - Laserfiche WebLink

Home Browse Search

. �... w. . �-�.�,� �.7 rte •= , APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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.Tins application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address q�Gf 1� q �A, City 1;7. Lot Size Y- AGS PM Owner's Name �a `� � �,5 Address 1 ti Q• 8p`a- 7f V ,5 Phone Contractor 1 AddressR-0, 1►�t`alft �� _ License Noa Phone a7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMP INSTALLATION I; SYSTEM REPAIR ❑ OTHER ❑ g/} r DISTANCE TO NEAREST: SEPTIC TANK r�0 SEWER LINES DISPOSAL FL1_ D. ' PROP. LINE ._._-- i FOUNDATION AGRICULTURE WELL OTHER WELL a�— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q l r t ❑ Industrial WOpen Bottom t N o❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SgGG E Specications r ❑ Public ❑l Other ❑ Delta Depth of Grout Seal S D Type of Grout 4 e L� El Irrigation vPCllOApprox. Depth r_❑ Eastern n Surface Seal Installed by v� rN Pt Repair Work Done El 'Type of Pump 5.f f In H.P. State Work Done Well Destruction ❑ Well Diameter 'F Sealing Material (top 50') 4 E N I Depth t Filler Material (Below 501 .9 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of ybedrooms .' I 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 4 Distance to nearest: Well Foundation -- - Property Line j _ f " LEACHING LINE ❑ 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 .. ❑ - F Fhereby 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 l 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 its issued,I shall employ persons subject to workman's compensa- tion laws of California." c The applicant u�stL,call for all�required inspections. Complete drawing on reverse side. Signed ►'e 1 t " Title: } Date: I DEPARTMENT USE`ONLY` 1 I - r Application Accepted by Date Area f Date Pit or Grout Inspection Date L� �/Fina1 Inspection.by Additional Comments: ❑ Stk 466-6781 . ❑ Lodi. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box•2009, Stk., CA 95201 FEE., AMOUNT DUE ---AMOUNT REMITTED- -CASH ""RECHVfD 8Y— ----DATE "" - PERMIT'NO. INFO tr +� _ +£H 13-241REV.1/85) y g�4 � EH 14-26 . C3 ! 6/ y ! 7-k b I