87-2856 - Laserfiche WebLink

Home Browse Search

71 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. 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-� I��• G i� 1.k1 City. Qk3i 12 0 Lot Size PM Owner's flame Gt � Address �J7 0 Gt i'Z tJ f-�I f�Cl .,. Phone 4� ` �76? T_:C,�jntr,actor Address_ ��1[a C)-+ Ys�- �el� License No,rg q��'� Phone TYPE OF WELLlPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER.❑ I: DISTANCE TO NEAREST:-SEPTIC TANK _..�� SEWER LINES .--.� DISPOSAL FLD:/-5-0 PROP. LINE 44!!�Q FOUNDATION AGRICULTURE WELL 74A OTHER WELL PITS/SUMPS ~, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �! ❑ Industrial XOpdn Bottom [I Manteca Dia. of Well Excavation li Dia. of Well Casing )[Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing >✓ Specifications j ❑ Public ❑ Other ❑ Delta Depth of Grout Seal s T of Grout ❑ Irrigation 0—K—Approx. Depth ❑ Eastern Surface Seat Installed by K h Repair Work Done ❑ Type of Pump H.P, j State Work Done Well-Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATITN ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence_ Commercial_ Other NumSer of living units: Number of bedrooms Character of soil to a depth of 3 feet: j t 4, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity Fr fVo. Compartments PKG. TREATMENT PLT. ❑ -�• Nlethod of Disposal # t 4 Distance to nearest: Well } Foundation r -- ?Property Line t LEACHING LINE s �� A A ��--�'Je�iota/-1 ❑� No. & Length of lines � Total length/sizo FILTER BED ❑ ,Distance to nearest: Well '} `� Foundation - Property Line SEEPAGE PITS ❑ Depth Size *Numb 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 withSanJoaquin 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 th(e 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;emp�oy persons subject to workman's compensa- tion laws of California." The applicant m t call for all required inspections. Complete drawing on reverse side. ' � + f Signed Kg Al1Ji.t1Y� Title: Date: FO EPARTMENT USE ONLY "t-1 Application Accepted by .�^Date Area IIr7 i r7tF J 17 Pit or Grout Inspection by / bate G Final Inspection by Additional Comments: _ LIQ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7 ❑ Tracy 635-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE ' r + INFO MOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT`N0.J p � A I f + EH1 -24IREV. 4 EHt -28