87-3847 - Laserfiche WebLink

Home Browse Search

APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 k PERMIT EXPIRES TYEAR 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 them Joa n Local Health District. p a G k Job Address ;2 ✓3 61 �� pv� I City Lot Size � � � PM r Owner's Name -e ✓Pi (dress Q Phone 4 �3 E i License No.o2,�a-Phone ?a- TY-PE -_��__— Address f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ,.. DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' p� r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -FOUNDATION -- .-- .--AGRICUL-TUREWELL-•- -----OTHER-WELE- - ---PIT5lSUMPS ` 1. k INTENDED USE TYPE OF WELL .,; PROBL'EM AREA CONSTRUC710N SPECIFICATIONS 1. ` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationJ Dia. of Well Casing (71 Domestic/Private 'i❑"Gravel-Pack "'0 Tracy Type of Casing Specifications - i-1 Public 17 Other Cl Delta y, ._Depth of Grout Seal Y- Type of Grout f T- t ' 11 Irrigation --Approx. Depth ( I Eastern Suflfice SiY5l-1 stalled by- Repair Work Done ❑ Type of Pump H.P. State Work Done _ r_ Well Destruction ❑ Well Diameter Sealing Material (top 50 I� T t Depth Filler;Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION [ ,REPAIR7ADDITION I] DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet:} 1 Installation will serve: Residence Commercial ' 1 Other Number of living units: A— Number of bedrooms' i Character of soil to a depth of 3 feet: A n _ W_ ater table depth " r - SEPTIC TANK Type/Mfg p - L L Y1 1;162f-'B:epacity _ No`Compartments PKG. TREATMENT PLT. ❑ �', Method of Disposal Distance to nearest: Well ' Foundation �(� Property Line LEACHING LINE No. & Length of'lines 14'X r Total length/size FILTER BED ❑ Distance lo:nearest: p Well t' Foundation 140 Property Line tom SEEPAGE PITS ('l Depth SizeNumber SUMPS it L Distance to nearest{? �W-. A !J 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. • -^ F, .f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fo?which this permit is issued, l 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." t i The applicant must call for all r rred inspections. Complete drawing on reverse side. t f0 77 Signed X -.,Title: &/A _ Date: ' 1 R DEPARTMENT USE ONLY Application Accepted by Date Area /11, Pit or Grout Inspection by Date i-'a','inspection by - Date, Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 11Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 FEE" mWAMOUNT DUfw T . + AMOUNT REfu11TTEQ CASH Y pREGEiVEQ BY4' L. �DAA PERMIT NO.INFOEH 13-24 I REV.I/m 5) EH 14.211 ��