87-2134 - Laserfiche WebLink

Home Browse Search

p APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I >[ ., (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 Coun Ordinance No.549 for sews a or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. GQ's Job Address "# City C. Lot Size PM ! Owner's Name r� t/e. rV' \' 14-f/ Address Phone __� Contractor Address t License No. Phone S~ TYPE OF WELL/PUMP: NEW WELL ❑, WELL REPLACEMENT ❑ DESTRUCTION ❑ - t PUMP INSTALLATION O. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK " SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION "`AGRICULTURE WELL '' OTHER WELL PITS/SUMPS _ f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing k L) Domestic/Private . ❑ Gravel Pack' ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ' ❑ Delta Depth of Grout Seal Type of Grout i ❑'Irrigation_ ,.,, --Approx.Depth_0 Eastern—_ _-Sur.face,Sea1 Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done l Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filter Material (Below 501 ` TYPE.OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.).,,,,,, Installation will serve: Residence✓'" Commercial—Other Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet J10A t, Water table depth r SEPTIC TANK ❑ Type/Mfg 19G Capacity r)6 No. Compartments r.. _ -- PKG. TREATMENT PLT. ❑ p Method of Disosal Distance to nearest: Well":__�� Foundation� Q Property Line _ t f 7 t] I len h/size j j LEACHING::LINEn--"No. & Length of lines 4 To VI� length./size. "ii� FILTER BED�, ` F41 ❑ Distance toI nearest: Well Foundation s— Property Line,-9 I ' SEEPAGE PITS ❑ Depth Size 1 Number t #'! SUMPS CF wDistance to nearest: � Well � Foundation Property Line i DISPOSAL PONDS ❑ 1 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, I shall not # employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signatur certifies the following:"I certify that in the performance of the work for which this permit isissued,1 shall employ persons subject to workman's compenSaI tion laws of California.' The applicant must call for all re wired inspections. Complete drawing on reverse side. - r Signed Title: Date: # F DEPARTMENT USE ONLY f - Application Accepted by Date Area /� r t Pit or Grout Inspection by Date Final Inspection by Hate Additional Comments: t# r , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy5 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 x° r ur- FEE AMOUNT DUE F AMOUNT REMITTED CASH r RECEIVED BY DATE PERMIT N0. H"7324:IREV:1ti+�a-s� INFO ,.�,�".. y NfA .