87-1454 - Laserfiche WebLink

Home Browse Search

4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 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. �J ) Ll i'1 J , O& O'S Address 1 r1 �{ City` Lot Size � PM V3. 1^ Owner's Name �� W C %I n, Address :2qD( I Phone %'` 1} Contractor Address "^ License No, Phon I TYPE OF WELL/PUM NEW WELL WELL REPLACEMENT ❑ I. DESTRUCTION ❑ PUMP INSTALLATION ❑' f SYSTEM REPAIR ❑ `�i `� OTHER; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSALPROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL r - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T "' ❑ Industrial ❑ Open Bottom ❑ Manteca,,,, Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy :Type of Casing Specifications c ❑ Public ❑ Other ❑ Delta Depth of-Grout Seal Type 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 INSTALLATIONX REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is j -.available within 200 fget.) U Installation will serve: Residence✓ Commercial✓ Other _Zen 014 Number of living units: f Number f bedrooms Character of soil to a depth of 3 feet: �-_D S)g n. Water fable depth SEPTIC TANK ❑ Type/Mfg Capacit�:Z jaCQ(x. No. Compartments i PKG. TREATMENT PLT. ❑ 4.0. u L- 1� 'Method'of Disposal Distance to nearest: 4 Well M0 Foundation Property Line LEACHING LINE ❑ No. & Length of lines -2 - /004 Total length/size _Dzo`. FILTER BED ❑ Distance to nearest: WeIIEv&tr 1 Foundation Property Liffe- SEEPAGE ineSEEPAGE PITS ❑ Depth 1S Size Z . Number rI SUMPS ❑ Distance to nearest: Well ) Foundation Property Line DISPOSAL PONDS ❑ 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, 1 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 applic t must tail a I req ired inspections. Complete drawing on reverse side. Signed `� Title: s�` .\_ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �� Area #, Pit or Grout Inspection byOat Final Inspection by Dat 3 Additional Comments: ❑ Stk 466-6781 VLodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all c to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. INFO CA } y / + EH 14-28 /3-28 V.i/8 5) 1, o 1, EH 1