87-267 - 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 ; 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 t "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;,,. i K`PQN Job �'Y`- * City / Lot Size PM Address Q -- Owner's Name �- X FORZ2 Address 7ZW 2V hone /0 Contractor / /&W /�I 5 Address o�� W/ License No.41�—y o > /Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION J0JfLa&-k'&4Afk.YSTEM REPAIR ❑ OTHER ❑ ~ " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern l!Srrrface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P.�/L State Work Done #CEA ,9eCAM PFFkC /,Z Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Q (No septic system permitted if public sewer is available within 200 feet.) fnstallation-will-serve:--Residence-- Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ + Method of Disposal iDistance to nearest: Well Foundation Property Line LEACHING�LINE3 t ►}t❑ No. & Length of lines l�`t� Notal length/size FILTER BED 4 1©; Distance-to nearest: Well Foundation fi:Property Line i SEEPAGE PITS ❑ Depth = Size Number SUMP S ----�•- ❑ _[]s Ince to,t nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I ha4prepared this (application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I) rules'and regulation's':afithe,�San Joaquinocal Health District. ( Home owner or licensed agent's signatur .certifies es the following:))-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." Contractors 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 applicanM l requi d n pections. Complete drawing on.rreevverrsse ide. k Signed X _ _:� Title: �./!�� Date: I FOR'DEPARTMENT,USE ONLY QQ Application Accepted b Date a— Area C)`+'._ T Pit or Grout.lnspection Date Final Inspection by f Additional Comments: s ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ; ^' antece 823-7104 ��❑ Tracy. .835-6385 Applicant-"Return all copies to: Environments eal h`RermitLServices m160i-.E. Hazelton Ave ;P.O. Box 2009, Stk., CA 95201 I y FEE .f 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. — �� k +"E14 13-24(REV.1 85) 1125 EH 14-26- 1