87-1014 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL,HEALTH DISTRICT 1 1601 E. HAZE T ON AVE., STOCKTON, CA + Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR:FRO.M DATE ISSUED (Complete in Triplicate) �. m +►, - � 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: ' r Job Address -.L �� nn 7-6 4 `' cSr ck d J f Ciry /�/Lot Size_;;( X N (J PM Owner's Name L'., Address r V&S r6'Az Phone 0 �- Contractor cs' r tl Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION .❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 v DISTANCE TO NEAREST: SE SEWER LINES DISPOSAL F LINE FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS "r INTENDED USE TYPE OF WELL PROBLEM ARE STRUCTION SPECIFICATIONS - ❑ Industrial ❑ Open Bottom ❑ ca Dia. of a avation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications k ❑ Public ❑ Of ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface'Seal Installed by. —.4 Repair Work D ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 l Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is I! available within 200 fee0 Installation will serve: Residence_ Commercial_ Other Number of living units: ' Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfgr Ca acit P Y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well - Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ .Distance to nearest: Well Foundation Property Line'" 4 SEEPAGE PITS ❑ Depth Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line'" A DISPOSAL PONDS ❑ e 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. 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 applicant must call for all re fired ' s ctions. Complete drawing on reverse side. Signed X TRW Date: 3 '� cj FOR DEPARTMENT USE ONLY Application Accepted Date Area Pit or Grout Inspection Date Final Inspection by Date .q Additional Comments: f ` . ❑ Stk 466-6781 .. ❑ Lodi 369-3621. .. ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CAS RECEIVED BY DATE PERMIT NO. + EH 14-28-24(REV,tin51 14 EH - I� �� V(3 -- ��Q J - �� (�� w �04 L� '](f l( p C7.Y j