87-2420 - Laserfiche WebLink

Home Browse Search

two ii 9 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 { a t 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. ! Job Address _�g s— :4 DD• Z&Z-,r t/D 7-ua City s7:K-r✓ Lot Size 34'&-k'2'L S� PM Owner's Name .�'r(4„: STG'rr/ �'�[j� Address 60 Be.1c 411 S*EA' l 57S_101 Phone Contractor Ir d_ �. Lt/D�t� Address 17,&Z .f7aEGB��T S'fi License No._SL7--C3 7- Phone .4 397 t-..- M __ K . _ _. TYPE OF WEI:L/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP'INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO,NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS INTENDEOUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation V} Dia. of Well Casing ❑ Domestic/Piivate ❑ Gravel Pack ❑ Tracy ' Type of Casing`tom Specifications f 1 Public F-I Other C] Delta Depth of GrouvSeal f Type of Grout I Irrigation _.Approx.,0epth, I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump-� s H.P. State Work Done Well Destruction El Well Diameter Sealin�rl-terial Stop 50'1 Depth I Filler Material (Below 501 TYPE OF SFPTIC WORK: NEW INSTALLAT.ION;I'l REPAIR/ADD N DESTRUCTION l 1 INo septic system permitted if pub sewer is 1 I . . available withi 200 Ile LI Installation will serve: Residence— CommerciaE_ Other Number of living un 'Number:of bedroomsq" ' Character of soil to a dept 6f-3'feet: -�!"" T`' �0�4�, Water table depth �© SEPTIC TANK': �Type/Mfg, t09-4 = G Capacity 1 Lie aa No. Compartments I -2— � PKG. TREATMENT PLT.70 I r Method of Disposal Distance to nearest: Well es Foundation. Property'Line"+ /Ba LEACHING LINE jX.No. & Length of_lines 4— gd r Total length/ze FILTER BED. ❑ Distance to nearest: Well ��'� FoundationProperty L ne -5-( SEEPAGE PITS r` h i I Depth Size _ Number l SUMPS I ❑ Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ V hereby certify that I have prepared this appiicatiori 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. 1 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 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 California." r� I The applicant Imust call for all required inspection Complete drawing on reverse side. Signed X h Title: Date. G`_Z9Tg7 FOR DEPARTMENT USE ONLY Application Accepted by Date ` (l Area t Pit or Grout I i pection by Date Final Inspection by Date Additional Commems: I ❑ Stk 466-6181 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 + Applicant - R.Lrn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INCK FO AMOUNT DUE ] AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. yq i EH 13-241REV.sirs sl t EH 14-29