87-3075 - Laserfiche WebLink

Home Browse Search

0S sem. APPLICATION FOR PERMIT $" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA V Telephone (209) 466-6781 (W60 l PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) �V��l 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. r ��{Xldrll PM r Job Address dear 1673 Lot Size- �ay06 Owner's Name (l.r facEyMr Address Q /lour Phoney t� ® � 9y,�Zr Contractor TI4AQj¢-rta^f Address y�0 ,��p.¢ �d 1�T13�.�k�_ icense No. S/BC}809-- Phone 6 TYPE OF WELL/PUMP: NEW WELL PE „ F WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK AV* SEWER LINES &A -DISPOSAL FLD. &/* POOP. LINE _IW-4- FOUNDATION _Arf .AGRICULTURE WELL &/A OTHER wELL_4PITS/SUMPS Aed' I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r jib Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing r ❑ Domestic/Private CR Gravel Pack ❑ Tracy Type of Casing Ne, Specifications 1-1 Public 11AVj'rwr/'1e ❑ Other ❑ Delta Depth of Grout Seal -3f Type of Grout /Utaf r!CArl..fi . I i Irrigation Mai —..Approx. Depth l 1 Eastern Surface Seal Installed by Vgrw. _ 4- Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501) Uj PE OF SEPTIC WORK: NEW INSTALLATION (l REPAIR/ADDITION l 1 DESTRUCTION I 1 lNo septic system permitted if public sew 1 rt available within 200 feet.) (h Installa ' will serve: Residence 'f_f Commercial_ Other tr Number of live nits: Number of bedrooms Character of soil to a of 3 feet: Water table depth SEPTIC TANK LI T Mfg Ca No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to neares . Well Foundation Property Line LEACHING LINE ❑ No. & Len lines Total length/size O FILTER BED ❑ Di ce to nearest: Well Foundah Property Line, t SEEPAGE PITS ['I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line OSAL PONDS ❑ I hereby certify that t 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 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 allrequirections. Complete drawing on reverse side. ; Signed X_�. /' p Title: ! bT� Date:? -, G, v �7 e FOR DEPARTMENT USE ONLY Q"�] k Application Accepted by Date r �7 y / Area fff Pit or Grout Inspection by Date 1 Final Inspection by C� Dat Additional Comments: DLL T O .GAS r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-710f-❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t? F FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY OATS PERMIT'NO. INFO CASH F + EH 13241REV.1/H51 F - EH 14 f u