87-4093 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781{ t,v... . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ltv;", (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 ievvage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I t. .. itJ r"`1. Cry 1Lot Size/D It PM Job Address ( PhoneV16 D J / (loOwner's.Name - Address. A Contractor Y ' Qgess' ` I - License No � Phone TYPE OF WELL/PUMP: .' 'NEW"WELL.❑ WELL REPLACEMENT ElDESTRUCTION ❑ PUMP INSTALLATION"❑z �C*SYSTEM REPAIR ❑ OTHER ❑ 1� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES—_ DISPOSAL FLD. � -PROP- WNE-r-" JV i. :FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS — �� INTENDED USE TYPE OF WELL PROBLEM:AREA CONSTRUCTION SPECIFICATIONS `�> Ll Industrial I" ❑ Open Bottom sr ❑,Manteca *' ';t{Dia. of`Wall Excavation t- 1 Dia. of Well Casing ❑ Domestic/Pririate, ❑ Gravel Pack ❑+Tracy, ' - �; t TypY_e of Casing i—Specifications'-- - ❑ Public ❑ Other ❑ Delta;5 Depth of Grout Seal Type of Grout ❑ Irrigation _—Approx. Depth. ❑ Eastern' Surface Seal Installed by , Repair Work Done ❑ Type of Pump A. # s H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') �M i. { g Depth Filler Material {Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION C1 (No septic system permitted if public sewer is S �M available within 200 feet.) Installation wild serve: Residence Commercial_ Other Number of living units: Number of bedrooms_ i Character of soil to a depth of 3 feet: Water table depth , SEPTIC TANK I�. ❑ Type/Mfg Capacity No. Compartments } PKG. TREATMENT PLT. ❑ Method of Disposal / y l' Distance to nearest: Well S&4Founclation � Property Line IfM LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well OeJO Foundation --� Property Line i SEEPAGE PITS:' ❑ Depth _ 2 7 Size Number 4dh i SUMPS I ElDistance to nearest-.\ � Welles/C7� 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. Home owner or licensed agent's signature certifies the following: "I-certifyahat 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 lust call for 9111 requirep inspections. Complete drawing on reverse side. Signed Title:_fL�r/Y+ _ Date: j FOR DEPARTMENT USE ONLY '—""!"`�- A�iplication Accepted"byDate Area r�� o�ry j Pit or Grout Inspection by Date Final Inspection by " Date Additional Comments: !. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy . 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ? I� gEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED SY DATE PERMIT NO. + E A 13.24(REV.1/8 51 tvEH W26 - i