87-4070 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT _ _ 4 SAN JOAQUIN LOCAL HEALTH DISTRICT � � 1 L. 601 E. HAZE�ION AVE., STOCKTON, CA 1 ""�:� Telephone 1209) 466-6781 v PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOW 187 (Complete in Triplicate) 21te-130-r y ENV1RWiENTAL IHE�AgqLTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d (A & -bh is made in compliance with San Joaquin.County Ordinance No.549 for sewage or No. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . r FOrn Q sero cl�� 5 J. S;r A 4"y _ Apmx. Job Address ko 4 JLJIf'-7 ri � r City I�-OU Lot Size PM Owner's Name r AL1-". Address —P_CL. SI �f W1 I( �J 7Z�� Phone - zZ �J r j Contractor ��1 J�� Address 3 2 f e/Q.- le .License No. 02gOl�I Ja Phone TYPE OF WELL!?UMP: NEW WELL iX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:=SEPTIC TANK SEWER LINES DISPOSAL FLDJO�*,.PROP. LINE,= FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l��Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing " L. Domestic/Private W Gravel Pack 0(Tracy Type of Casing___ 10W Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal fM I - Te of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 �{ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is n_ available within 200 feet.) Ill Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number f SUMPS ' ❑ Distance to nearest: Well Foundation - Property Line ; DISPOSAL PONDS ❑ - <,V ; 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Taws, 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 -r 1 employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature k 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." The applicant ust call for all r wired inspections. Complete drawing on everse side. w � �/� Signed rQS. Title: V��Pvfi LS Date: $ ARTMENT USE ONLY Application Accepted by Date � .� Area Pit or Grout Inspection by .Date/& z Final Inspection by Date yy Additional Comments: F ❑ Stk 466-6781 ❑ Lodi 369-3621 d Manteca 823-7104 D Tracy 835.8385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r INFO FEE AMOUNT DUE AMOUNT REMITTED 'Zi K RECEIVED BY. DATE PERMIT NO. + EH 13-24(REV, / ��V� l EH 10.29 [ ' CSO �� 14--7-r-""r- r