87-243 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) k 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 1 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. s `1 Job Address 1 1. rlV� ��r1 City Lot Size c X0 &rt S PM Owner's Name 1!,_ 1?Yt 5 Ll yN Address Phone ContractorUa lie - Address License No�4q-3 Sa Phone 3 0 TYPE OF WELL/PUMP: NrW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ _ [ DISTANCE TO NEAREST: SEPTIC TANK n P Ke— SEWER LINES A_VAk DISPOSAL FLD. PROP. LINE FOUNDATION J�r� '_ __ AGRICULTURE WELL 7i r1� OTHER WELL O'lll fi -_• PITS/SUMPS F &Ae RV\ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial 00pen Bottom ❑ Manteca Dia. of Well Excavation l 1' Dia. of Well Casing 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Tref Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout C",e. ❑ Irrigation 'ZO"pprox. Depth El Eastern Surface Seal Installed by 04- Repair Work Done El -Type of Pump �0.C.k . H.P. lSr State Work Done Well Destruction ❑ Well Diameter Sealing Material /top 501 • Depth Filler Material (Below 501 , <TYPE OF-SEPTIC WORK: NEW.MSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is "available within 200 feet.) Installation will serve: Residence— Commercial_ Other z Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ' ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number 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.- -- - x - n - i 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 became subject to workman's compensation laws of California."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." _ ( The applicant m st call for all required inspectiorM, Complete drawing on reverse side. Signed Title: r _ Date: f FQR EPARTME T USE ONLY Area 7 Y d l Application Accepted by J Date } Pit or Grout Inspection by Date t Final Inspection by Date I Additional Comments: ❑ Stk 466-6781 .Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 " - - - ..FEE 1 AMOUNTfbUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT''NO. INFO CASH +.EH 13-241REV.1/a5) 'EH 1428