87-52 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,,STOCKTON, CA Telephone (209) 466-6781 3 F t PERMIT EXPIRES "I YEARtFROM.DATE ISSUED '- s , (Complete in Triplicate) xr w 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. !� City Lot Size� � . vPM Job Address ` a , A/fnn�-'.. - Adres ds` .. m Phone � - 7326 Owner's NameN ....Jr rtn,�_IT rto m S„L v_.+.,...r••wr..^a icense No.903q i D �AJS� PhoneContractor Address f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IV DESTRUCTION ❑ O } PUMP INSTALLATION LD SYSTEM REPAIR [2 ✓ THEIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, _► . DISPk?SAL FLD. f PROP. LINE FOUNDATION AGRICULTURE WELL ',OTHER WELL PITS/SUMPS i ' > r^' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIOMSREGFFICATIONS fi El Industrials ❑ Open Bottom El Manteca Dia. of Well Excavation ' Dia. of Well Casing Type of Casing -' "' Specifications ❑ Domestic./Private ❑ Gravel Pack ❑ Tracy YP 9 i 10, ❑ Pubiic ❑ Other ❑ Delta Depth of Grout Se91 Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern .Surface Seal Installed by Repair Work Done C] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing"Material (top 50') Depth. Filler Material (Below ') TYPE OF SEPTIC WORK: NEW INSTAL ION ❑ REPAIR/ADDITION MeDESTROCTION ❑ (No septic sys$tem permitted if public s6wer is "�. .6,�, tavailable withW200 feet.) In'tallatiol will serve: Residence 0 Commercial Other I: umber f bedr oms � Number of.living units: N QQ "`ek= 11_. Water-&Ie depth Character Pf soil to a depth of 3 feet: Ll, a SEPTIC;TANK El Type/Mfg Capacity No' Compartments Methodlof Disposal PKG. TREATMENT PLT- ❑" Distance to nearest —WeN � Foundation Property Leine~ / 1 7f f LEACHING INE No. & Length of lines "' i - Total length/"size 3 / FILTER BED f. EJDistance to nearest: Well Foundation Property L niL e'*= %J SEEPAGE`PITS ❑ -Depth w Size umber- I i SUMPS ❑,.. Distance to nearest: Well - Foundation ( Property Line fl. fie; DISPOSAL PONDS ❑ § a 1 hereby certify that I have prepared this application and that the work will be done in keccordance with San Joaquin county'ordinan f s, sta e-4 ws, and rules and regulations of the San Joaquin Local Health Diric . -- . *� Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for°which this r sub-its issued, I shall not employ any person in such manner as to b4ome subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies the following: "I certify that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The appiica ust c for all requi d inspections. Complete drawing o r verse side. p� , - Date: v Signed X ' Title: F R DEPARTMENT USE ONLY } 87'1 Area d Application Accepted Date " ' � 'T164-c7` LI,.+E -orf •74-^JE-' T,� -AdjG Gt>>'`�--5 i ate Final Inspection by �F� Date t Pit or Grou In pection by V Af6 Q �[kcFrr6� aF LF�4cf(.. tr �� R T c ,�E45 1 w S wra n�E Additional Co ments: �u� ,� J P ,prSOy fSt js j ❑ Stk 466-6781 ❑ Lodi 369-3621 J,,,,,,;,,,D—Manteca._8217104.......M,...-©Tracy-W5.6385- f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I �( FEE CK RECEIVED BY DAT€ jPERMIT'NO. INFO AMOUNT DUE4 'AMOUNT REMII�TED�. CASHP + EH t3-24(REV. rv- +. EH 14.26 `