87-4237 - Laserfiche WebLink

Home Browse Search

3 - APPLICATION FOR PERMIT "I 7f ? 4 l ' �n SAN JOAQUIN LOCAL HEALTH DISTRICT �5'3 1601 E. HAZEL T OlN AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1:'I AR FROM DATE ISSUED r�� r , — ,Omplete.. Triplicate) � � 3 ( �J- (C .in, ( :�SrO d f4 � Application 1s hereby ma�e to the San Joaquin Local HealthDistrictfob a permit to construct and/or install the work herein described.This application is F 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. h �� ph! k, U, 4 1/ fa4e- PM � City Lot Size � I Job Address ©J A- Address j " pl,4 z A, -S�� Phone Owner's Name �!, I L At�� E101-1 f�Ai�u� �i�CenseNo.*�r a �Phane4/,6g `'�Lfg✓t' Contractors ��r 7A L� Address �� Y. TYPE OF WELL/PUMP: NEW WELL J, WELL REPLACEMENT ❑ DESTRUCTIONsp�❑ �V.-�f PUMP INSTALLATION ❑ I� SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA :` CONSTRUCTION SPECIFICATIONS LL ElIndustrial ❑ Open Bottom ❑ Manteca I Dia. of Well Excavation Dia. of Wel! Casing ' iL ❑ Domestic/Private l�Gravel Pack �YTracy Type of Casing— Specifications f'7 Public ❑ r f 1 Delta Depth of Grout Seal Type of Graur 44 A— i IVdP,Is, y`�Lt r� b I I irrigation UAB Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted it public sewer is \ available within 200 feet.) �{ r Installation will serve: Residence— Commercial_ Other' Number of living units: Number of bedrooms I� Character of soil to a depth of 3 feet: I�. Water table depth SEPTIC TANK ❑ Type/Mfg I�. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well. foundation Property Line IM LEACHING LINE ❑ No. & Length of lines I� Total length/size FILTER BED ❑ Distance to nearest: Well 11 Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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. 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." Contractor's hiring or subcontracting 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 applicanust call for all require ctions. Complete drawing on reverse side. l�r 9-7�� Signed X Title: ,/ ,Y _ Date: I IM i FOR DEPARTMENT USE ONLY �y I Application Accepted by Date / /-- Area l Pit or Grout Inspection by Date - Final"Inspection Date F Additional Comments: " M ❑ Stk 466-6781 ❑ Lodi 69-3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Seryices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED, CASH RECEIVED BY DATE PERMIT'NO. INFO a EH 13-24(REV.I/H 5) � �r�-� /� } i� ��,� � � ' ` 5 EH 14-26 v k Y