87-765 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I 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 City J-601 t` Lot Size PM Owner's Name tidressd Phone(10) 2Z-^ )Lv$D Contractor Address License No..2_ a,1515 Phon IG 3t3 TYPE OF WELL/PUMP: 3 NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE S�e FOUNDATION AGRICULTURE WELL OTHER WELL_:�L � PITS/SUMPS INT NDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t r ._ Dia. of Well Casing ❑ Domestic/Private )4 Gravel Pack ❑ Tracy Type of Casing P6C Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 360` Type of Grout r IJ Irrigation �Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Z2of —. Seating Material (top 501 ol'tt#iD��►g�e Depth ` Filler Material (Below 501 T F SEPTIC WORK: NEW INSTALLATION ❑ REPAfR/ADDITfON ❑ DESTRUCTION ❑ (No septic system permitted if public sewer available within 200 feet.) Installation will se Residence_ Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: r table depth SEPTIC TANK Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well tion Property Line LEACHING LINE ❑ No. & Length of lines length/size FILTER BED ❑ Distance to st: Well Foundation Pro Line SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line SAL PONDS Cl 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 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." The applicant must call for all r uired inspec' s. Complete drawing on reverse side. I,TGL/K, IAL&CC&_t1✓ Szi Title:_ 11lL, ��IaLcJ� Date: �o _c� s,p�-® f,� r E USE ONLY Application Accepted by Date _.. Area Pit or Grout Inspect! Date )zZ Final Inspection by Dat' !_C Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. EH 3-24(REV rias) �� s ( J /;�� C-� EH 14-28 ��l