87-2731 - Laserfiche WebLink

Home Browse Search

r w , APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT =pAYM��T R�GF-1'1lED 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 jUL 1987 f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1Complete in Triplicate) tNViRONMENTAL HEA tH ?9W4A RV10Eatron is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instail the work herein de r apphc made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ruies and Regulations of the San Joaquin k Local Health District. r Job Address 3125 E. Orane Street City AC o Lot Size 10 000 S .ft 4'M I Owner's Name _San 3Caa in County_ Address 1810 E. Hazelton Avenue Phone 944-2281 Public Works Department - ;., -__.. .., .{ - L _ " er Address b License No. Phone Contractor Add TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 2 SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES N A DISPOSAL FLD. PROP. LINE 25 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial C Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing Zan ❑ Domestic/Private SO Gravel Pack ❑ Tracy Type of Casing Steel Specifications Attache {}`7;Public T ii Other F1 Delta Depth of Grout Seal 200' rdn• Type of Grout Cement GrOUt I irrigation 55a.Approx. Depth I I Eastern Surface Seal Installed by— COntX'actor r Subl;lersible 50 Repair Work Done U Type of Pump H.P. State Work Done Well Destruction Wetl Diameter .Sealing Material [top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residenc• —t Commercial�,-Other- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ! SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 7 Method of Disposal r Distance to nearest: Well Foundation Property Line " I LEACHING LINE = No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line I SEEPAGE PITS : 1 Depth f Size Number SUMPS t-' Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I I hereby certify that I have prepared this application and that the worst 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: 1 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: ;1-carz:fy.that.in.the tce 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 all for all required ins lions. Complete drawing on reverse side. �7 7 Signed X Title: Director of Public WorkS Date: _ ` `fel HENRY I. HIRATA F DEPART ENT USE ONLY r Application Accepted by Date Area 0 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Sik 466-5781 ❑ 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 . r - t FEE AMOUNT DUE J AMOUNT REMITTEDC RECEIVED BY DATE PERMIT NO. INFO SEN t}7.IREY.i-x.51 Err