87-2117 - Laserfiche WebLink

Home Browse Search

Z3b APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON,AVE., STOCKTON, CA 1 Telephone {2091 466-6781 t . PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED t (Complete in Triplicate) r r 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 h San Joaquin County Ordinance made in compliance with No.549 for sewage or No. 1862 for well Ipump and the Ryles and Regulations of the San Joaqui Ppn t:II i 1, Local Health District. . ` City s. Lot Sae Job Address A4f � I ,5/5(�� Cao e,Qn kPhorie Zai/ 6 o C.e 4_ Address Owner's Name P Contractor Address ""� License N��Z�J3 Phone TYPE OF WELLlPUMP: NEW WELL E' WELL REPLACEMENT ❑ QESTRUCTION ❑ I SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION PROP. LINE SEWER LINES ��D � - DISPOSAL FLD. � DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL 3 k rr INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Excav on r Dia. of Well Casing p Industrial Ll Bottom ❑ Manteca Specifications Pack Type of Casing �DomesticlPrivate Ll Other Pack ❑ Tracy Depth of Grout Seai Type of Grout G ❑ Public ❑ Other ❑ Delta ^ El Irrigation �APprox. Depth ❑ Eastern /Su ace Seal Installed by Repair Work Done El Type of Pump H P State Work Done Sealing Material atop 501 � Well Destruction ❑ Well Diameter Filler Material (Below 50'1 — Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIfl1ADD1TION ❑ DESTRUCTION ❑ avlailabpe�wt in 200 feet.) tted if public sewer is Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Water table depth . t Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ElType/Mfffg Method of Disposal PKG. TREATMENT PLT. ❑ f Property Line Distance to nearest: Well Foundation I f •, r Total lengthlsize _LEACHING LINE ❑ No. &i Length of lines Foundation PropertylLine' � FILTER BED ❑ Distance to nearest: Well -f +W r r Number 's SEEPAGE PITS ❑ Depth Size Foundation Property Line ri ' SUMPS ❑ Dista to nearest: Well 'r 3- 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, a d rules and regulations of the San Joaquin Local Health District. s- rmance f the work for s permit is issued, Home owner or liceshall not nsed agent's signature certifies the following: "I dertify thansation lt in the aws3of California,"Contractor'sihir ng or sub-contracting lsignaturre employ any person in such manner as to become subject to workman's comps certifies the followin I certify that in the performan�'e;of-the work#or wFnah tYiis p`ermii is issued, l shall empty persons subject'to workman's compensa 9:„ , tion laws of California." The applicant.Aust call for all r uir�d inspe`tions. Complete drawing on reverse Sider+€. l - � Dale: Signed X, ART MEIIIT'1}5E.ON41P- t . Area Application Accepted by 3 e I -F-inahinspedtion by' £ - Date Pit or Grout Inspection by ' Date - Additional Comments: r 4 ❑ IVlanteca 823-7104 E; Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369-3621 Applicant- Return all copies to: EMR&mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t r t FEE AMOUNTI DUE AMOUNT,REMITTED CK RECEIVED BY - DATE. PERMIT'NO�.7 CASH—-- a - INFO � � '6-7 VQ +EH 13-24IREV-1/B5l � '�. a EH 1426