87-1590 - 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 L'' cal 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. ' r /� Job Address Z3 C ��11 (_ fill CityK�' otf Size `rte X�� PM Owner's Name 'ti.n�kms..-..{/�(L,IPiA!S Address Phone ✓—I 5 contractor t9FTfkL-(,:S QW-- Address—L000 At ulytylu License No. kLl7hone - $TYPE OF WELL/PUMP: NEW WELL ❑ :• WELL REP,LACE_MENT M) DESTRUCTION ❑ f PUMPINSTALLATION p^ ,,.SYSTEMtREPAIR I❑ OTHER ❑ DISTANCE TO NEAREST: TIC TANK SEWER LINES^ DISPOSAL FLD.. - PROP. LINE FOUND N AGRICULI�(URE WELL. OTHER WELL �* PITS/SUMPS _ 'ts INTENDED USE TYPE OF WELL PROBLEIIII AREA CONSTRUCTION SPECIFICATIONS F-1 Industrial L3 Open Bottom O eca - t Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Ll Gravel Pack ❑jTracy' Type of Casing} l �� Specifications ❑ Public 11 Other El-Delta of Grout Seal F Type of Grout ❑ Irrigation J4pprox. Depth ❑FEastern Surface Installed by--- P Repair Work Done ❑ Type of Pump H.P. •► State Work Donetl Well Destruction ❑ Well Diametei '*tri Sealing Material (top 50'1 s- Depth IFiller Material I6e1nw'50`l7A*� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION!CJ D_ESTR_UCTION INd.septic system permitted if public sewer is I 1 ' vailable within 200 feet.) Installation will serve: Residence_.. Commercial_ Other � # Number of living units: Number of bedrooms .1 Charactr'of soil to a dF of 3 feet:. w 1< Water table depth SEPTIC TANK Type/Mf( 7 C p city -- No Compartments y ? PKG. TREATMENT PLT. Method of Disposal f Distance to nearest: Well t-1 %--Foundation Property Line r } LEACHING LINE ❑ No. & Length of lines I Total length/size .` FILTER BED ❑ Distance to nearest: Well Foundation PropertyLine SEEPAGE PITS Depth XISVSi -Siie�` Number SUMPS (❑` Distance to nearest: L"Wb1F�Fouridation------oll—�Propeify l-ine DISPOSAL PONDS ❑ 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. . 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." Contiactor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which thisrtpermit is issued;'I shall employ persons subject to workman's compensa- tion laws of California-" F R_ -- — ,�.,,,, � r I -%d I i The applicant t cal f r all rquiredd inspections. Complete drawing on reverse side. Signed X /�'�J /QIt�O'—� Title: `hf�m�G-s" Date: ?J FOR DEPARTMENT USE ONLY Application Accepted by Date — Area ,. } I Pit or Grout Inspection b Date Final Inspectitio by �y f� Date Additional Comments: -2S f 'C C �b ' ` N �� ° r LJStk 466-6781 F1 Lodi 369-3621 71anteca 623-7104 El Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE , I INFO AMOUNT DUE AMOUNT REMITTED CK VAMH RECEIVED BY DATE PERMIT�NO. + EH 13-24[REV.i/H 57 } EH 1428 J 4