87-4146 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA I Telephone (209) 466-6781 .[PERMIT EXPIRES 1 YEAR FROM DATE ISSUE t (Complete in Triplicate) is I dinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin District for a permit to c Application is hereby made to the San Joaquin focal Health' onstruct and/or install the work herein described. This application made in compliance with San Joaquin County Local Health District. I R PM t� City Lot Size Job Address �y ? Phone Address Owner's Name r Phone j PUMP 4 U t � � License No. JV � �' Address DESTRUCTION ❑ Contractor WELL REPLACEMENT ❑ NEW WELL Br. OTHER ❑ 1 TYPE OF WELL/PUMP: -.PUMP INSTALLATION e A SYSTEM REPAIR ❑ ) t l+9 DISPOSAL FL �PROP. LINE SEWER LINESCSY�._ PITSISUMPS�u/` 'I DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELLOTHER WELL Ag FOUNDATION INTENDED USE TYPE OF,WELL PRO13L, EM AREA Dia. of Well Casing CONSTRUCTION SPECIFICATIONS ❑ Open Bottom Ll Manteca Dia. of Weil Excavation Specifications L]T Industrial ❑ Tracy Type of CasingJ1 I ElDomesticlPrivate l�ravel Pack Type of Grout 3 n Delta Depth of Grout Seal F1 Public I l Other]^ a » -- -Surf ace Seal installed by IZ1Trigation " '—..APprox. Depth l I EasternState Work Done _ T e of Pump y ly-..—'r H.P. i Repair Work Done [c}�Typ Sealing Material (top 50') Well Destruction ❑ Well Diameter �--- i Depth 1 Filler Material (Below 50') tic system permitted it public sewer is s y available within 200 feet.I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRlADDITION l l DESTRUCTION l 1 o sap f � • Installation will serve: Residence Commercial— Other —_-- Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 fee1.t: Capacity No. Compartments ry SEPTIC TANK ❑ Type IMf9 } Method of Disposal t PKG. TREATMENT PLT. ❑ j foundation__� Property Line `� Distance to nearest: Well ' (_,,,� Total length/size r ❑ No. & Length of lines ` LEACHING LINE I Foundation Property Line t ❑ Distance to nearest: Well 3 FILTER BED; ' r ' Number I } DeptSize SEEPAGE PITS h Property Line SUMPS. l L1 Distance to nearest: Well Foundation I DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the fallowing: "I certify that a the performance of the work for which this permit is issued, I she not emp oy any p f the work for which this permit is issued,I Sheik employ persons subject to workman's compensa l arson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring subject signature certifies the following: "I certify that in the performance o l tion laws of California." The applican st call for all required inspe tions. complete drawing on reverse side. f r Title: Date: Signed X •�� ' MENT USE ONLY t - Date Area Application Accepted by Date L ,q//'' '� Final Inspection b, _ ` Pit or1rout Inspection bate y D ( -� �! vlrlaV�l�iS ', Additional Comments: ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man`eca 82371 Stk., CA, 95201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, RE AMOUNT REMITTED CEIVED BY CK N - DATE PERMIT"NO. - FEE AMOUNT:DUE, n INFO � + ♦ EH 13-24(REV.If H 5) tEH 1428 - - ,