87-2898 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 f# �i PERMIT EXPIRES 1 YEAR 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. [�t� , � Job Address 1 City J ),'16/1- Lot Size PM Owner's Name J�Z 10.4 H_4 ' Address l J 1� �/ Phone Contractor' , vAdss` !'7JY � �` License Not PfioneA9-,3363 .TYPE OF WELL/PUMP: u NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f- ; to INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private:' ❑ Gra'vel Pack ❑ Tracy Type of Casing Specifications M Public' rn+0 her n Delta Depth of Grout Seal Type of Grout —.— F.I Ifriga i n Approx. Depth I i Eastern Surface Seal Installed by -T _ �. Repair Work Done ❑ -Type.of Pump H.P. Stat-e Work`Done _ w Well ❑estrucUon ❑ WeII Diameter- - Sealing Material flop 501 DepthFiller Material (Below 501 CIAO A TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITEON LI"DESTRUCTION (No septic;system permitted if public sewer is 1 { available within 200 feet.) Installation will serve: Residence— Commerciah 1. Other 1 I! Number of living units: y Number of bedrooms Character of soil to a depth of 3 feet: I' p � � � Water table depth , SEPTIC�TANK ❑ Type/Mfg Capacity_____"_ r NolCompartments PKG,`THEATMENT PLT. ❑ 6Metlod of Disposal I Distance to nearest: Wellri # undation y� Property Lune � L LEACHING LINE ❑ No. & Length of lines � ' w ¢- F g - Total length/size FILTER BED ❑ Distance to nearest: Well Fau da on `Property'Line SEEPAGE PITS I 1 Depth Size rNumber V I SUMPS; 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." 9 The applica m call f r II required i ctPons. Complete drawing on reverse side. Signed X Title: Date: ; FOR DEPARTMENT USE ONLY Application Accepted by Date 7 ' `� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: .S- ' LI Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE�+/�. PERMIT-NO. + EH 1}24'IREV.1/H51 EH 14-26- i