87-3133 - Laserfiche WebLink

Home Browse Search

x. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hetaby 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. / Job Address City LOG/ Lot Size.. rS,P C PM Owner's Name Address _ Phone ��. Contractor +fir Address lldb License No.307-1-/ -Phone— TYPE hone-TYPE OF WELL/PUMP: 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ; ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public n Other M Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx, Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth _ Filler Material (Below 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION f I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial w Other Number of living units: _J_ Numbergf bedrooms Character of sail to a depth of 3 fast: L �I/,— Water table depth SEPTIC TANK ❑ Type/Mfg O ✓C' Capacit y ld_ �— No. Compartments 2— PKG. PKG- TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 1040 1 Foundation Property Line Cry \ LEACHING LINE ❑ No. & Length of lines 0 Total length/size ZO IF FILTER BED ❑ Distance to nearest: Well -10 r Foundation_ Q t �_ Property Lina SEEPAGE PITS i l Depth 3 Size_ 3 6 .r ' Number—s i SUMPS Ll Distance to nearest: Well Foundation 4 mm Property Line� ..- DISPOSAL PONDS F1 1 hereby certify that I have prepared this application and that the work will be done in accordance-with San Joaquin county ordinances, state laws, nd- . T rules and regulations of the San Joaquin Local Health District. . Home owner or licensed agent's signature certifies the following: 'Tcertify 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." The applicant must call far I required inspections. Complete drawing on reverse side e + Signed X Title A ).cIC Date: qFOROPARTMENT USE ONLY Application Accepted by Date OA 9 7 Area Z Pit or Grout Inspection by Date_ Final Inspection by Date Additional Comments: ► ❑ Stk 466-6781 D'Lodi 369-3621 ❑ Manteca 823-7164 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P. Box 2009, Stk., CA 95201 FEE INFO ,+SUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EW t11-26 a-2alsaEv., �s: EW V ,06 - 1�7-