87-261 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ii 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i yy r w (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 Sap Joaquin Local Health District. i.3 City Lot Size PM Job Address �* , . fes`_ Address Phone Owner's Name _ 4 .1 D n "L ( Phoney , Contractor Address License No. ; TYPE?OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i # PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TON EST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r El Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ 'Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ElOther ElDelta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by r 7 Repair Work Done ElType of Pump H.P. State Work Done ! Well Destruction ❑ Well diameter Sealing Material (top 501 Depth Filler Material (Below 501 i.. TYPE.OF SEPTIC WORK: NEW Y( TALLATION f7 REPAIR/ADDITION DESTRUCTION ❑ (No septic system permi7publicwer is available within 200 feet.Installation will serve: Residence 1 Commercial— -OtherINumber of living units:� Number-of bedrooms Wateir table depth f .Character of soil to a depth of 3 feet:_• j SEPTIC TANK ❑ Type/Mfgr Capacity No_Compartments ¢4 t � Method of Disposal PKG. TREATMENT PLT. ❑ t i Distance to nearest: Well Foundation Property Line. a LEACHING LINE No. &'Length of lines_ Total length/size ' FILTER BED ❑ Distance to nearest: i Well. Foundation Property Line M It r i � „ ' SEEPAGE PITS ElDepth Size Number nearest: f Well y a SUMPS F) Distance to Foundation Property Line r DISPOSAL PONDS ❑ l 1 1 hereby certify that I have prepared this applicatiomarid that the work will be'done-in accordance with.-San Joaquin county ordinances, state laws, and t ; rules and regulations of the San Joaquin Local Health District. { s f 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, 1 shall not employ any person in such manner as to become subject to workman's compensation Jaws 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 must call for all required inspections. Complete drawing on reverse side. 1 ': i Title: � f Dated Signed 7�"` _ FOR DEPARTMENT' USE ONLY \ r 1. 3 Application Accepted;by !� Date Area i - I .� . �. . . --- e_...- �! --Date x'97 Pit or Grout Inspection by Date Final Inspection by 7 Additional Comments: ❑ Stk; 466 8781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 L3 Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. 80x.2009, Stk., CA 95201 1 - ._ - .. a F.EE AMOUNT DUE AMOUNT REMITTED CASH ..— RECEIVED BY DATE ;PEEFR ]INFO+ EH13-24IRE F EH 14.28— _ z "