87-3302 - Laserfiche WebLink

Home Browse Search

Y� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone'(209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E j (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 Cciunty Ordinance No.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r " !a O /+.- p Job Addres , J c CityID �""t` Lot Size PM Owner'sS 1Dc �+�h F G tx tf Aan r f �. L�_ �^ y Owner's Name Address �!K!� ✓ t/l N r �S T�W�1/( Phone l _03 33 j - Contractor F—Kgk Kli• Address l&7 OAKS Sf'Ff*M#bV "License No. ''t&M L Phone /544 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION Ll Q�� y PUMP INSTALLATION SYSTEM REPAIR OTHER J44 , •,`� { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE �� S FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casingi. ❑ Domestic/Private ❑ Gravel Pack.. ❑ Tracy Type of,Casing Specifications' b f� 1-1 Public ❑ Other Ll.Delta Depth of Grout Seal Type of Grout + I E Irrigation �..Approx. Depth l 1 Eastern Surface Seal Installed by F Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 501 s Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residence Commercial— Other i Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK- ❑ Type/Mfg'L Capacity - - No. Compartments J PKG. TREATMENT PLT. ❑ # Method of Disposal rf Distance to nearest: Well Foundation Property Line A LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth ^� Size Number SUMPS ❑ Distance to'nearest: Well 'Foundation Property Line DISPOSAL PONDS ❑ iI 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 i employ any person in such manner as to become subject to workman's compensation taws 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." The applicant must call for all.ree_gluirud� NF inspections. Compllet_e,dr/a ing on reverse side. Signed x5/ A�� Cir F [4( l kG `Tle: •'` f+ �I`Ei �C�O Date: FOR DEPARTMENT USE ONLY > p i Application Accepted:by �`� Date o - Area Pit or Grout Inspection by ' e Inspection by JVIA - Date Additional Comments: :<r C] Stk-�466-6781 . -,,C] Lodi.. 369-3621. ❑ Manteca 823-7104 �.8'Tracy 835-6385 7 i Applicant- Return all copies to: Environmental Health-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 i 7FEE AMOUNT DUE., _ AMOUNT REMITTED CASH CK RECEIVED BY DATE 'PERMIT'NO..E +.-EH 14-24 IREV,I/H5) � f !/ ;') Fj'