87-2429 - 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 7 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 740 CityA e2 Z2� Lot Size PM Owner's Name l � r, ,�pm�,�l.Address Phone W1W Te,e Contractor Address C License No.��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS PUMP INSTALLATION ❑ SYSTEM_ REPAIR ❑� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL;FLD. PROP. LINE FOUNDATION �.._. AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ! Specifications ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal Txpe of Grout El Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by { Repair Work Done ❑ Type;of Pump I� H.P. State Wo`r'k Done A056IM& &2a4CD Well Destruction ;0 Well Diameter Sealing Material (top 50') Deptfl Filler Material (Below 501 TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) .� 1 Installation will serve: Residence_ k'k Commercial_ Other i w Number of living units: I NumbeF of bedrooms -aaracter ofsoilto a depth of 3 feet. Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ j , E i Method of Disposal ~ w Dance to!neatest W'e11k. -i Foundation Property Line l LEACHING LINE ❑ No. & Length Total length/size r FILT�R BED ❑ Distance to nearest: 111� .F_oundation Property Line 1 � SEEPAdli PITS ❑ Depth Size 1 Number 1 f SUMPS i ❑ Distance to"nearest: Well Foundation Property Line DISPOSAL PONDS Elv hereby certify'that I have prepared this application and that ifle 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:','l certify that in the performance of the work for which this permit is issued, I shall not employ any penton in such manner as to become subject to workrridn'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." I{ The applicant I r all r spections. Corhplete-drawing o r se e. Signed it Title: ; Date: F 07PAATMENT USE ONLY Application Accepted byDate 6 4 Area Pit or Grout Inspection by 1�1 S, 40 _— Date f j Final Inspection by Additional Comments: t ❑ Stk 4664781 ❑ Lodi ' -36211 ❑ Manteca 823-7104 I ❑ Tracy 83556385 ! Applicant- Return all copies to,-�vironmenta['Health-Pe`rrnit7Sir ices 1601 E.—Haiekon AVe., F. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDd4rCASH'CKRECEIVEDRECEIVED 9Y 1. DATE PERMIT N0. INFO tEH13-24(REV.1/05) � EH 14-28 y�-% Z