87-3927 - Laserfiche WebLink

Home Browse Search

{ �� } � APPLICATION FOR,PERMIT ,. ! SAN JOAQUIN LOCAL HEALTH DISTRICTij� 1601 E. HAZEL T ON AVE., STOCKTON, CA , t Telephone (209) 468-6781 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 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. � ,Q g Job Address ' j( /� City Lot Size PM l f Owner's Name �, L�/'> j�Qzier Address ► L n + U r cePhone d i, Tri ►Ib N� J ,�J �G ,�D 1 6 t!? _ 6�V 1 i Address oleo d t5 IUe �d t�/lES L License No. 37i��/a 3 Phone �? 7 Q Contractor l� 1. t. TYPE OF WELL/PUMP: NEW WELL —'/ WELL REPLACEMENT LJ DESTRUCTION LJ PUMP INSTALLATION itJ- SYSTEM REPAIR ❑ OTHER ❑ ! D(STANCE`TO NEAREST:-SEPTIC'TANK fil6nl --SEWER LINES -,off.. DISPOSAL FLOi PROP. LINE i FOUNDATION AGRICULTURE WELL THER WELLAbgk--.._ PITSlSUMPSA6A /F— INTENDED USE ��Uf TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Instrial 1s f Open Bottom ❑ Manteca Dia- of Well Excavati¢n Dia. of Well Casing du Domestic/Private Gravel Pack El Tracy Type of Casing ((� �a -e-� Specifications 1 a51� O her LI Delta Depth of Grout Seal SQ ' Type of Grout .Aizf —. f FI Public lea _ - 1 r I i Irrigation pC -Q..Approx. Depth 11 Eastern �ut ace Seal Installed bye I Repair Work Done ❑ Type of Pump ?'• H.P. 3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 v Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDIT(ON I 1 DESTRUCTION-1..1m1-No.septic system permitted if public sewer is available within 200 feet.) d Installation will serve: Residence_ Commercial_ Other 4 Number of living units: Number of bedrooms le ` Character of soil to a depth of 3 feet: Water Water table depth et SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well. Foundation Property Line E. r LEACHING LINE ❑ No. & Length of lines x Total Length/size FILTER BED ❑ Distance to nearest: Well " Foundation Property Line C ' SEEPAGE PITS I I Depth Size- Number SUMPS ❑ Distance to nearest: Well. Foundation Property Line 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."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 applican must ca11 for all fequirW inspecti ns. Complete drawing on reverse side. 4 `Date: f 0' A Signed X Title: FOR DEPARTMENT USE ONLY _ Date Area Application Accepted by Pit or Grout Inspection Dates sVU` Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i 3 FEE AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT-NO. INFO + EH 13-24 1 REV.I/A 51 / -� � EH 14-26