87-2499 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN:LOCAL HEALTH DISTRICT A+{M V E� 1601 E. HAZELTON AVE., STOCKTON, CA P � Telephone (209) 466-6781 R PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2+ C�5Ap - y (Complete in Triplicate) iv,14the plication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hefrcanon is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 for well/pump and the RulesSan Joaquin Local Health District: ' Job Address City of Size ' a PM Owner's Name 1'L� Address 45L=V Phone Contractor Address)/ License No. Phone p TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑" SYSTEM REPAIR ❑ OTHER W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL"FLD. PROP. LINE FOUNDATION Y AGRICULTURE WELL OTHER WELL PITS/SUMPS Y INTENDED USE TYPE OF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (" I r Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 2fPublic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout s El Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done if Type of Pump, H.P. State Work Don r i Well Destruction ❑ Well Diameter Sealing Material stop 50'1 r i Depth I Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ lNo septic system �¢xu �' p permitted if public sewer is \ t• available within 200 feet.} Installation will serve: Residence_' Commercial_ Other . Number of living units: Number of bedrooms If . } Character of soil to a depth of 3 feet: "' k Water"ible depth i SEPTIC TANK ❑ Type/Mfg r�'kt Ca act t r ti i.- PKG. ." P ty .a"No. Compartments PKG. TREATMENT PLT. ❑ `Method of.Disposal h F Distance to nearest: Well Foundation Property Lihe # LEACHING LINE ❑ No. & Length of lines Total`IengthYsiie " FILTER BED ❑ Distance to nearest::., Well Foundation { Propeft Line 7 , S i SEEPAGE PITS ❑ Depth Size Number E } r SUMPS ❑DistanCe—Co nearesi: Well 'Foundation Property Line—"..- - .--- �T DISPOSAL PONDS p 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. 4J�k 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." Contractors 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 c or all required inspections. Complete drawing on reverse side. 1 Signed Titla: �ia+�t.J Date: - FOR DEPARTMENT USE ONLY zz Application Accepted by Date Area i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 465-6781 ❑ 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 -AlFEE INFO MOUNT"DUE AMOUNT REMITTEp CK RECEIVED BY DATE PERMIT''N0. + EH 13-24IREV.t/851 3 v 11� V 00 EM laza