87-3976 - Laserfiche WebLink

Home Browse Search

e 1 . APPLICATION'FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 t k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 the San Joaquin Local Health District.' { Job Address ' ) � !'+` City I 4114!1� Lot Size PM r Owner's Name _ Address Phone IQD7'10 &w7, �� t� hones f� Contractor -ek Address QJ" License fQo TYPE OF WELL/PUMP: - . NEW WELL 11 -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 } 3 ❑ Industrial ❑ Open Bottom ❑ Manteca (Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack- ❑ Tracy Type of Casing Specifications i-1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth i I Eastern Surface Sea! Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth r Filler Material (Below 50') TYPE OF SEPTIC WORK; NEW INSTALLATION 1.1 REPAIR/ADDITIONX DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) 17 D Installation will serve: Residence a Commercial_ Other ��! F "#—Y w�T Number of living units: Number of bedrooms t Characier of soil to a depth of 3 feet:'f Water table depth SEPTIC TANK ❑ Type/Mfg 1 p� [r., Capacity UIVO No. Compartments PKG. TREATMENT PLT. ❑ 1 4 1 Method of Disposal R ; Distance to nearest: Well�fJ__, Foundation w Property Line —LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Ilk SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ 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. Nome 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 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 Califor " The applicant call for requir d " cti o plate drawing on reverse side,/7 Signed X Title: Date: t R DEPARTMENT USE ON - Application Accepted by Qna�_ I,akDate f Area Pit or Grout Inspection by ' Date Final Inspection by'- Date`/ € Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385,; Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO MOUNT DUE .� AM!lO��UNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-291REV.S/N51 MAO r'-'Z.—Y7 Y'7-39, EH 14.26 - - �✓ '