87-392 - Laserfiche WebLink

Home Browse Search

wo it APPLICATION FOR PERMIT !! SAN JOAQUIN LOCAL HEALTH DISTRICT � F ° 1601 .E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466-6781 U�Lx 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. Job Address -E+ 3 - City S Lot Size y X .5 PM r Owner's Name _��eS - c� 1f9kelgAddress a rr7 �+ 31�`c�f S�`, S[OC.J37O!1 Phone a' Z Contractor m4.)b e'lr- Address f4b-1,dP_ CA's ClLbOV 6 License No. Phone TYPE OF-WEL UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ HER ❑ DISTANCE TO NEAREST: C TANK SEWER LINES DISPO LD. PROP. LINE FOLINDAAGRICULTURE WELL ER WELL" PITS7SUMPS' INTENDED USE TYPE OF WELL --,PROBLEM AREA CONSTRUC4091SPECIFICATIONS _ # ❑ Industrial ❑ Open Bottom ❑ Ma - "3 Dia., All Excavation r Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casings Specifications ❑ Public 71-Other"`-'—""" E] De "Sf 1 r u Seei "-Type-of Grout— ❑ Irrigation ---Approx. Depth ❑ Ea n Surface eat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONA(No septic system permitted if public sewer is ;- av ilabie within 200 feet.) Installation will serve: Residence_ Commercial_ Other �' F Number of living units- Number of bedrooms p Character of soil to a depth of feet: F54 Water table depth SEPTIC TANK Type/ city No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: ell Foundation Property Line 5 LEACHING LINE ❑ Nb.`&_ ength of lines'"_ 4 Total length/siza FILTER BED ❑ Distance to Weare Well undation Property Line I SEEPAGE PITS " ❑ Depth Size t �' Number SUMPS ❑ Dfsta a to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ i t 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 G rules and regulations of the Sari Joaquin Local Health District'_ Home owner or licensed agent's signature certifies the following f}r 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 C Rforni ' The applicant st ca for all reV ins t ns. Complete drawing on reverse side. 3 X Signed Title:• Date: �� t FOR DEPfN ARTENT USE ONLY Application Accepted by Date �-��" Area Pit or Grout Inspectio Date Final Inspection by Dat&3:17-�� IN - Additional Comment ❑ Stk- 466-6781 ❑ Lodi, 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environme Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1� INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. + EH 241REV.i/as) W 5` Q ...r S7 EH 1429 I