87-4063 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I. 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f; i (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 welUpump and the Rules and Regulations of the San Joaquin Local Health District, 1 Job Address A City Lot Size PM p� `7q (� n � T.Owner's Name..._� V.Y... ,C��-e, _ .. Address 5 J` :"' &f 5 kD Phone235 -6 Contractor-__ � (t Address O. - go V "Liconse No. Phone) a S TYPE,OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOf4. 0 i a t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP6§AL FLD.=PROP. LINE FOUNDATION AGRICULTURE WELL OTHEWWELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t f ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Wel! Excavation-- Dja. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing -`Specifications Z. —+r fl Public Ll Other Cl Delta Depth of Grout Sea] t Type of Grout I I Irtiranon J --.Approx. Depth i I Eastern Surface Seal Installed by Repair,Work Done ElType of Pump H.P. 'State Work Done_ Well -1 ❑ Well Diameter Sealing Material (top 50') "` 6- Depth Filler Material (Below 50% - TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION I I DESTRUCTION]'( )'(No septic system permitted if public sewer is ! / ' ^• available within 200 feet.) _v ; Installation will serve: Residence r Commercial_ Other i Number of living units: Number of bedrooms 3 z Character of soil.to a d7Type/Mii)' of 3 feet: �}fla h e., f Water table depth k SEPTIC TANK p s_'CO3;' CVre,+ Capacity a a No. Compartments PKG,.�TREATMENT PLT. ❑ 4s � Method of Disposal 3 Distanceto nearest: Well ��Foundation�_ Property Line_ -- T LEACHING LINE Nom.Length of lines 3Ct-0 i Total length/size 6 FILTER BED ❑ (Distance to nearest: Well '�. FoundationProperty Line �.- SEEPAGE PITS r' I ] Depth, Siie Number t SUMPS s - LZ Distance to nearest: Well Foundation x Property Line DISPOSAL4PONDS C7 ;6j r 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: -i Home owner or licensed agent's signature certifies the following: "I certify thavin 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." i The applicant must call for all required inspections. Complete drawing,on..reverse side. A-7 Signed X IK.t Title: Q.i�� Date: �3 t ) s j� FOR DEPA MENT USE ONLY Application Accepted by I Date A9 �j / Area JN i W1 �� Pit or Grout Inspection by j Date i. Final Inspection by ` Dat Additional Comments: I 0 Stk 466-6781 ❑ Lodi 369-3621 ❑Manteca 623-7104 0 Tracy 835-6385 � ) Applicant..- Return all copies to:.Environmental Health Permit/Services 1601'E. Hazelt ntAve.,-P..O. Bax 2009, Stk., CA 9520.1 i, _ INFO FEE AMOUNT QUE AMOUNT REMITTED 'GASH t 'RECEIVED BY DATE PERMIT-NO + EH14-24IREV.tiksl S�[{� C �0 EH 14-2fS e]r 1 G -