87-76 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 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 4 Lot Size J PM j r . ' Owner's Name J2 I Address q1 G Phone $ !1 / Contractor 1 -r Address PQ (2Y 1 0 7. License No- jj Phone ~� TYPE OF WELL/PUMP: NEW WELL ❑ r WELL REPLACEMENT`❑ DESTRUCTION ❑ ' "*PUMP-INSTALLATION-❑- wSYSTEM-REPAIR,C7eOTHER,❑-- ---- ,- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WCL"—PROBLEM AREA CONSTRUG'TION SPECIFICATIONS } ❑ Industrial ❑ Open Bottom,,, El Manteca,+?�J , .Dia:-of-Well-Excav_ati6n Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public "Cl the Delta Depth of'Grout Saab Type of Grout ❑ Irrigation _�_ 4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ xType of Pump H.P. I' State Work Done Well Destruction ❑ WeIhDiameterA- Sealing'-Material (top 501 Depth Filler Material (Below-501- TYPE OF SEPTIC WORK:4 NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is C� , available within 200 feet.) Installation will serve: Residence.= Commercial_ Other Number of living units:Al ' Number of bedrooms Character of soil to a depth of 3 feet:,, Water table depth SEPTIC TANK V Type/Mfg 4A Capacity—U-0-0 No. Compartments PKG. TREATMENT PLT. fl j '_ 1 _ .- �.yt` q ' Method of Disposal i Distance to nea _V. Well Foundation-__2�O._._._.. ,Property Line LEACHING LINE � No. & Length ofilihe`s -=h � �i�_ . . � ,�Tlo_#��I'length/size kFILTER BED ❑ Distance do nearest: -"kWel1 Foundation rltt Property Line _ SEEPAGE PITS ❑ Depih Size Number SUMPS EDDist6ce-to nearest: Well I Foundation Property Line DISPOSAL PONDS ❑ 1 L 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 reg u lations;of the San Joaquin Local Health District. , r . 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 Califamia."Contractors 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." r S The applicant must call,forAll squired inspections. Complete drawing on reverse side. F � Signed X__0A, ! VTiW a Title: o 6 Date: FORyPEPARTMENT USE ONLY Application Accepted by // '!OI/I Date / "� Area D k Pit or Grout Inspection by Date I - Final Inspection by &4104011 Date. /107 Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369421 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all:copies to: Environmental'Health Permit/Services.1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 L FEE INFO AMOUNT DUE( AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. +EH14-24iREV.tiasl EH 1 � ` 0.28 / I b r '