87-3502 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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. " i Job Address 13 6�G uNloA! /Zo^o City MTC^ Lot Size 2 ACR,eS . PM Owner's Name V /M 01 V.1 A.' Address SAA I' Phone- - B I Contractor IA1 ��afa�� Address /SO 1301TOov 4JA License No. �y3ti+� Phone6S84- I g TYPE OF WELL/PUMP: w NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' s ! PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.F PROP. LWE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial I ❑ Open Bottom , 171--Manteca Dia. of Well-Excavation Dia. of Well Casing ❑ Domestic/Private ---:—El-Gravel-Pack--- ❑ Tracy-4-Type-of Casing - `.-Specifications F1 Public t ..n Other f-1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation .-Approx. Depth "1 1,Eastern # Surface Seal Installed by I -Report Work Done ❑ Type of Pump v H.P. State Work Done ' Well Destruction ❑ Well Diameter �!_ -Sealing Material {top 501 "Y .• } t �+ ! Depth '' ' Filler Material (Below 501 TYPE OF SEPTIC.WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION 1;1 (No septic system permitted if public sewer is t. y + �.y i available within 200 feet.) r Installation will serve: Residence-At-, Commercial_. dOther ="= Number of living units: r" Number of= edrooms ; Character of sail'to a de th of3' feet �1NrJ Water table depth p s -SEPTIC TANK E� Type/mfg F L Capacityy0 No. Compartments 1 PKG. TREATMENT PLT. ❑ �� MethodDisposal y Distance to nearest: Well,§Z Foundation 0 Property Line 2 ++ LEACHING LINE r Lor"No. & Length of lines �U Total length/size yV _ FILTER BED 'E Distance to nearest: Well 1c7 -�-. Foundation Lo_ Property Line=5 L r .,SEEPAGE PITS I-i �kDepth' ' `10' Site x f0 X q �[t� Number I I P, �..., `,SUMPS ' [Sol-Oisiance to nearest: Well 100' Foundation__.�_ Property Line DISPOSAL PONDS f ❑ w I hereby certify that I have prepared this application and that the work will be done in accordance`with Sari Joaquin county ordinances, state laws, ander .M rules and regulations of the San Joaquin Local Health District. � ''� �° I 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 no i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signafu `r> ) certifies the following: "I certify that in the performance of the work for which-'twos permit is issued,Ishall-am to i Pe p e employ persons subject to workman's compensaF� tion laws of California." L \ The applicant must call for all requed inspections. Complete drawing on reverse side. 1 r tiY"LTitle:r ._.-d-lR.tNRt� + 1 Signed X Date: FOR DEPARTMENT�USE ONLY ApPlicatiori Alice t by Dateterea / � t IJ' l f 7 Pit or Grout Inspection y �Da ` Final Inspection by bate�/ # Additional Comments: ❑ Stk 466-fi781I ❑ Lodi 369-3621 ❑ Manteca823-7104 ❑ Tracy 835-6385 \ Applicant- Return all.copies to: Environmental Health Per it/Services 1601.E. Hazelton Ave- P.O. Box 2009, Stk., CA 95201 jFEE AMOUNT DUEf AMOUNT REMITTED �K RECEIVED BY GATE PERMIT NO. NFO-♦ EH 13-26 EV.I/x51 U�y ,0UO �f -T- 4� EH 14-ZB �-Q�Q