87-2930 - Laserfiche WebLink

Home Browse Search

t �Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTO.N, CA Telephone (209) 466-6781 , PERMIT EXPIRES 1'YEAR FROM DATCISSUED (Complete in Triplicate),, - 01 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 forwell/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address l� L ►" ' ` City " - -� Lot Size PM Owner's Name Address `' 4 •'WC �'hone 1 l r Contract dress 0 4 icense No.r 7� � Phone 715 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR"D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLDIt PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —I'd - f INTENDED VSE TYPE OF'WELL r PROBLEM AREA CONSTRUCTION SPECIFICATIONS * ; {❑ Industrial I❑ Open Bottom ❑ Manteca Dia- of Well Excavation <Dia.'of:'Well Casing I © Dome`sfic/Private``` ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 .Public. ° F1 Other ,{ F1 Delta Depth of Grout Seal'-. Typ.of Grout- . J i-34 I I Irtigation --Approx. 'Depth I 1 Eastern Surface Seal Installed by 1 Repair Work Done. '❑ Type of Pump H.P. State Work Done Well Destruction * ❑ Well Diameter Sealing Materia"I{op�50') Depth rivlaterial {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION N1 :REPAIR MIDDITION K DESTRUCTION I I INo septic system permitted if public sewer -_- available within 200 feet.) Instalfation+will•serve: Resigence Co mercial_ Other ~' _ Number of livi g,Its: / -�•f1E tuber of roams ( �<.0 —Character of soil,to a depth�of 3 feet: Water table depth SEPTIC TANK 4)❑ Type/Mfg Capacity No. Compartments Z ,—PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Fo ndation Property Line , LEACHING LINE &-,-No. & Length of lines Total length/size d r FiLTER-BED! .I // Distancd'to nearest: Well :� Foundation tOf Property Line SEEPAGE PITS I Iepth Size Numbef SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑O . 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 t rules and regulations of the San Joaquin Local Health District. Home owner or,lice nsed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not € empioy_any_person in such manner as to become subject to workman's-compensation laws of California."Contractors hiring-or_sub-contracting-signature. 4 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 Ca'fornia." The applicant m s call for I r ui d inspections. Complete drawing on rave e e Signed Xf Y Titl: Date: k FOR DEPARTMENT USE ONLY I Application Accepted by f Date Area- 12— Pit 2Pit or Grout Inspection by , ,_ / .Date Final Inspection by Date * Additional Comments:, •° ` ❑ Stk . 466-6781 ❑ Lodi' 369-3621 ❑ 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 95201FEE f INFO AMOUNT DUE AMOUNT EMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-24(HEV.i/n sl EH 14-2e ,¢