87-2052 - Laserfiche WebLink

Home Browse Search

a A - 'A APPLICATION FOR PERMIT }}� SAN JOAQUiN LOCAL HEALTH DISTRICT k I, 1601 E. HAZEL T ON 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 aiipermit to construct and/oi install the work herein described.This a ' made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 for well/ um and the Rules and Regulations of the San is Local Health District. p p e9 Joaquin Job'Address # F C��'t1//' Lot Size PM Owner's Name Address O fY Phone Contracto Address TYPE OF W LL/ UMP: NEW WELL^Q License Ifo. Phone D140 ea WELL REPLACEMENT ❑ DESTRUCTION 4 PUMP INSTALLATION-0- SYSTEM REPAIR ❑ ER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LiNES r _ -' DISPOS PROP. LINE FOUNDATION AGRICULTURE'WELL � x ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR ON SPECIFICATIONS ❑ Industrial If Open Bottom ❑ Manteca D' , of Well Excavation ❑ Domestic/Private C1 Gravel Pack fDia. of Well Casing ❑ Tracy Type of Casing T ❑ Public', ' Q Other ❑ De Specifications ` Depth of Grout Seal rw: D.Irrigations _meq Type.of Grout --Approx. Depth Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. , Well Destruction ❑ Well D' ter State Work Done Sealing Material (top 50'1 epth Filler Material (Bel $0'1 TYPE OF S WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ IN o septic system permitted if public sewer is r Installation will serve: Re idence! Commercial Other available within 200 feet.) Number of living units: Number of bedrooms — Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Di osaI Distance to nearest: Well _ Foundation Property Line k LEACHING LiNE ❑ No. & Length of lines FILTER BED Q Distance to nearest; Total length/size Well Foundation F-_ Property Line ._ y SEEPAGE PITS ❑ Depth Size .Number " SUMPS ❑ Distance to nearest: Well Q �_ Foundations property Line DISPOSAL PONDS q 4 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,f shall employ persons subject to workman's compensa- tion laws of California." The applicant mu II far a eq "red inspections. Co plate drawing o reverse side. Signed Titl Date: f - FOR DEPARTMENT USE ONLY ,� r Application Accepted b*by . � Date Area Pit or Grout Inspection Date Final inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C] Manteca 823-7104 ,;O Tracy 835-63135 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE ; MT DUE AMOUNT REMITTED CK CASH RECEIVED By DATE PERMITNO. + EH 13-24 fREY,t/85)EH 1429