87-431 - 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 1 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 made in compliance with San Joaquin County Ordinance No.549 for or No. 1862 for II um and the Rules and Regulations application is Local Health District, p eg Joaquin IrNfJ�� Job Address f Q L aQ City Lot Size PM Owner's Name L l� S/ Address C/vQ ( �YYJ sh qCf u1/0-7, f Phone 72 Contractor vfi Address ��(��., 6.Phones` TYPE OF WELL/PUMP: License No. ZsZ 7 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELLOTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS ❑ Industrial ❑ Open Bottom ❑-Manteca Dia. of Well Excavation 1-1Domestic/Private 11Gravel Pack E3Tracy Dia. of Well Casing Type of Casing Specifications ❑ Public' ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation ---Approx. Depth ❑ EasternType of Grout ,r Surface Seal Installed by Repair Work Done ❑ Type of Pump H.p State Work Dane Well Destruction ❑ Well Diameter Sealing Materia! (top 50'} Depth Filler Material IBelow SO'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is Installation will serve:' Residence available within 200 feet.I - Commercial_ Other 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. ❑ c r Distance to nearest:- " ell Method of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BEDTotal length/size ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS Property Line 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. ssued, I shall not Home owner or licensed agent's signature certifies the following: "!certify that in the performance of the work for which this permit is i 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 ciired in ctions. Complete drawing on reverse side. Signed - - Title: 4 1 Date: FOR DEPARTMENT USE ONLY Application Accepted by _Z Date . _ Area Pit or Grout Inspection by Date � ,.,C Final In coon by ate Additional Comments: AV", prl'Yl�-/ a 15, j S PQr)l r �- Se ❑ Stk 466-6781 u r ❑ L 369-3621 ❑ Manteca 823-7104 L3 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �Dhea® l GfJa� 6-�o- 5G s hIl-5-e r� FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.t/e5) Az- EN 14-26 �� d Cj fes_