87-4199 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �L SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 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. ' ` � Y Job Address u/ w r �y City of Size' �C /�r PM � ww ,yj��} �� 1 „Owner's Name f Address &• z�"'-"�"t' ntt6 e- Contractor�f� I Address // ` ' License No. Phone Phoner� TYPE OF WELL/PUMP: _f3EW WELL ❑ -WELL REPLACEMENT ❑ DESTRUCTION ❑, ' PUMP INSTALLATION ❑ { SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK-:- SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL4. ,PROBLEMAREA CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ❑ Open Bottom ❑ Manteca .:Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T�,�y Type of Casing Specifications I 1 Public CI Other �Re'lfa Depth of Grout Seal Type of Grout- I ,: I 1 Irrigation �-Approx. Depth l I Ea t"to Surface Seal Installed by Repair Work Done ❑ Type of Pump = .''i H.P. State Work Done_ 6 Well Destruction ❑ Well Diameter Ael., Sealing Material Itop 501 Depth ► Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION t 1 DESTRUCTION i I (No septic system permitted if public sewer is I available within 200 feet.) +11 Installation will serve: Residence 1; Commercial_ Other I Number of living units: _/_ Number&f be rooms�_ a Character of soil to a depth of 3 feet: WateT,table depth SEPTIC TANK 10'"Type/Nlfg"7"` Capacity /10 0[} -Nn- ompartrnents �s PKG. TREATMENT PLT. ❑. L Method o�isposal (7 .�. € Distance to nearest: Well Foundation_` r--.,Property Line LEACHING LINE ❑ " No. & Length of lines z 1 Total length/size kv f a FILTER BED ❑ ' Distance.to nearest: Well . ..,Foundation_ `l Property Line f k SEEPAGE PITS /,,,*Ll 1 Depth_*_C Size. rw+"rw tY Number-.--- - x SUMPS L" Distance to nearest: Well Foundation Property Line b. . DISPOSAL PONDS ❑ k . ' I hereby certify that I have prepare this application and that the work will be done in accordance with San Joaquin count ordinances, state laws, and i Y Y P P.. PP q Y .. 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 I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature k 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 st call for "II required inspections. Complete drawing on reverse side. " Signed X! Title: �d 1,4-u Date: I i FOR DEPARTMENT-USE ONLY. 2 Application Accepted by f Date Ik Area I Pit or Grout Inspection by Date Final Inspection by Dater/- Additional Comments: 0 �f' / ElStk 466-6781 ❑ Lodi f 369-3621 ❑ Manteca BM-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.; P.O. x 200A,/tk.AA"4500e FEE . AMOUNT DUE AMOUNT REMITTED CK K3 CA RECEIVED BY DATE PERMIT'NO. r INFO + EH13-241RE .%/Hsf �� O �YL * EH 14-26 4. I ..