87-4057 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT Mari wA r SAN JOAQUIN LOCAL HEALTH DISTRICT Vj� J 1601 E. HAZEL T ON AVE., STOCKTON, CA /�+1T Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (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 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 �s /d Job Address /19 &I 1't/i� 11' 7-11:7 fG� City nom" C Lot Size PM Owner's Name h Address �o< �yfJ /U� /7 / /.LJcx�� Phone �ca��taa Contrat`tb(�bu Address G'�r5 r -�D � License Mo � -TYPE OF WELL/PUMP: t NEW-WELL Q—_ WELL REPLACEMENT 0— DESTRUCTION ❑ PUMP INSTALLATION i SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK & SEWER LINESDISPOSAL FLD.� PROP, LINE FOUNDATION / AGRICULTURE WELL /J . L OTHER WELL PITS/SUMPS e. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS // ❑ IInn�fustrial Open Bottom ❑ Manteca Dia. of Well Excavations AR°' Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ e, �rj Specifications (public n Other F1 Delta Depth of Grout Seal Oft Type of Grout �B,,'ne ra _ I i Irrigation ._Approx. Depth / i I Eastern Surface Seal Installed by i' Ile r- Repair Work Done ❑ Type of Pump �/ Q .__ H.P. 3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is - available within 200 feet./ Installation will serve: Residence_ Commercial_ Other 17 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. Compartments r PKG. TREATMENT PLT. ❑ _ Method of Disposal - Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line CS 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, ane--cl 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 subiect-to-woman's compensation laws of California. Contractor§"tforing or'sub-contfa-c-fing slgnature'� 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 require nspections. Complete drawing on reverse side. Signed X Ctm �I�-rtitle:_(tedA`1.�7- -r1. Date: FOR DEPARTMENT USE ONLY Application Accepted by 1 Date Area Pit or Grout Inspection by f Date j Final Inspection by Date �-� Additional Comments: ❑ Stk 466-6787 ❑ Lodi 369-3621 ❑ anteca 823-7104 IN Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO a.EH 13-24 MEV.1?n 57 ' 0Li EH 14-26