87-2247 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Job Address J�_.. _ _t"�'t f` City Lot Size ��a PM l �p U Cl Owner's Name Address r Phone F � iracto`rL r s--- — 'r `-" '�'�—License No:�YF.L+ -.P_hone` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ( PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r _. ❑ Industrial + ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.'of Well Casing �r t ❑ Domestic/Private .} ❑ Gravel Pack ❑ Tracy Type of Casing f Specifications f l Public ❑ Other ❑ Delta Depth of Grout Seal N1. _ yType of Grout I I Irrigation Approx. Depth y r'l I Eastern Surface Sea! Installed b t Repair Work Done D3 'Type of Pump H.P. State Work Done II c Well Destruction' AON Well Diameter. Sealing Material (top 50') , lDepthT'�"'� Filler Material IBelow 50'1 * _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIONP9.,Mo septic system permitted if public sewer isl_,� !// available within 200,feet.l Other Installation will serve: Residence_ Commercial_ - Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: $ Water table depth �Q SEPTIC TANK ❑ Type/Mfg Capacity Na. Compartments ]+ PKG. TREATMENT PLT. ❑ I Method of Disposal \\\ Distance to nearest: Well Fdundation Property Line LEACHING LINE 0 No. & Length of lines � f •Total length/siz�Line FILTER BED ❑ Distance to nearest: ' Well Foundation Propert , SEEPAGE PITS I I Depth Size T .1Number SUMPS ❑ Distance to nearest: Well - Foundations 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. # k 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 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 p s issued, 1 shark employ persons subject to workrna s compens$ tion laws of California." � ''ti ©4 R N, The applican must call for all require inspections. Complete drawing on reverse side. Signed X Title: � Date: JOF ! FOR DEPARTMENT USE ONLY f`�a,ATOtisA ation Accepted by Date �'� Area 3 cptrout Inspection by Date.6-1a--67 Final Inspection by Date `p J 1 Additional Comments: CALg, '++ , ❑ Stk 466-6781 0 Lodi1139-36203 ❑ Manteca 623-7104 ❑ Tracy 835 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t . ' FEEI CK AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. / INFO _ _ t