87-3498 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District./r�/rJ p/� �7 Job Address �n�e� AEC City SmL/?�Lot Size PM k1_1~/C 5TM1�' Owner's Name eKQss Phone Contractorl�'I els i } dress License No. / Phone J TYPE OF WELL/PUMP: NEW WELL;R? WELL REPLACEMENT ❑ — -DE&T-RUCTION ❑ PUMP INSTALLATION,9q+ SYSTEM REPAIR El OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION Q?/94 AGRICULTURE WELL OTHER.WELL`-,_- -__-_ PITS/SUMPS LQP4 INTENDED USE TYPE OF WELL- PROBLEM AREA CONSTRUCTION SPECIFICATIONS�'I ❑ Industrial ❑ Open Bottom r ❑ Manteca Dia. of Well Excavation Dia- of Well Casing r Domestic/Private "Gravel Pack f ❑ Tracy Type of Casing Specific tions 17 Public "-n Other r r Delta Depth of Grout Seal Type of rout I i Irrigation �Approx. Depth fI 11 Eastern Surface Seal Installed by hWA&&" 5- & - Repair Work Done ❑ Type of PumpI-sl�13 H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 I Depth i F)tl6r Material (Below 50') T F SEPTIC WORK: (NEW INSTALLATION I I REPAIR/413DITION i I DESTRUCTION-[ 1 (No septic system permitted if public.sewer is I?�available within 200 feet:) Installation will serve` ince Commercial_ Other ' i i , --- Number of living units Num , droorns�- Character of soil to a depth of 3 feet: i n., Water table depth SEPTIC TANK ❑ Type/•Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance t1 ne rest: Well Foundation roperty Line LEACHING LINE ❑M1lo. &-Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this appiication"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 cEiriifies_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 subiact 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 _f all r r spections. Complete drawing on r ide. // ry Title: -Date:.. _1 -/! ! F EPARTMENT USE ONLY _ / Application Accepted by �\* -,Date 9 /b I \Area ` 6/ -EinalanspectionDatePit_or--Grout Inspection y r r ` Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3el ❑ 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 INFO FEEAMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT NO. +.EH 13-24 MEV.I/85) v EH 14-26