87-3010 - Laserfiche WebLink

Home Browse Search

l APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he,eby 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 3�N1 d dr. [ �} r...._ oS Q-"-� ^'"f- City Lot Size PM Owner's Name r? O+'t a�+1 £ Address Do X- 1034 f" �e C Phone + Contractor S�aN�. l c1t'I Address , E) `, 3 al's ca, License No.`k'? ),14_0 _Phone TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a 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 4 ❑ Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing Specifications f'l Public n Other ❑ Delta Depth of-_Grout Seal . i Type of Grout I f Irrigation --Approxi Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P- State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t 3 DESTRUCTION I l .(No septic system permitted if public sewer is T f available within 200 feet.) Installation will server Residence_ Commercial-- Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:! Water table depth - ' 'SEPTIC TANK ❑ 'Type/Mfg Capacity No. ents PKG. TREATMENT PLT. ❑ * Method of Disposal r Distance to nearest: Well F ion f " Property Line LEACHING LINE ❑ No. & Length of i9 Total length/size FILTER BED ❑ Dista nearest: Well Foundation Property Line SEEPAGE PITS I t Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line I _W5110-SAL PONDS ❑ } I hereby certify that I have prepared this-application and that the work will be done in accordahce 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 sub-contracting signature F 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." f t The applicant must call for all squired inspections. Complete drawing on reverse side. t Signed XTitle: E r �- T— Date: A J S;. I f FOR DEPARTMENT USE ONLY Application Accepted by Date �7— Area Pit or Grout Inspection by Date Final Inspection by � Date Additional Comments: i D Stk 466-6781 Ll Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmentat Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. @ D�^s ` + EH13-24 MEV,t/MW �J, UO 3� �} ..-✓ EH 14.26 J