87-2695 - Laserfiche WebLink

Home Browse Search

� x APPLICATIC rr"OR PERMIT ' SAN JOAQUIN LOL''AL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.-STOCKTON, CA TI e ephone (209) 466-6781 Cr.iw� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y r r F ;Al r .. x >..-(Complete in.Triplicate), i►, ,. fApplication 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 i made in compliance withSanJoaquin County Ordinance No 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Healfh`Distnct. ,� �: e Job Address �t Q,Y �x yCity -Cot Sizer PM �' Owner's Name ,,. m R Address �, i�r Phone Contractor_ C�n. n fJl� Address a1 License No.�L�Phone TYPE OF WELL/PUMP: - 'ANEW W.ELL,.❑,..�... - WELL'REPLACEMENT ❑ DESTRUCTION ❑ E �' � PIJMIP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ ..r E ! { DISTANCE.TO NEA131i$T ,SEPTIC TANK SEWEA-LINES DISPOSAL FLD... PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS r INTENDED USETYPE 6F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia. of Well Excavation -� l _- Dia. of Well Casing Domestic/Private ❑.,GraveL.P.ack—„�.,,-..❑_Trac -- ---� ' ' Y _ Type of Casing J� ' 1 :5 eci#ications . _R _ ❑ Public ❑ Other LJ Delta Depth of Grout Seal Type of Grout F-1 Irrigation _Approx. Depth Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done a r Well Destruction ❑ Well Diametertti Sealing Material /top 50'i Depth Filler Material /Below 50'1 TYPE OF SEPTIC WORK: NEW.INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Numb jer of bedrooms 1 Character of soil to a depth of 3 feet: ! Water table_depth SEPTIC TANK LIType/Mf f. J. Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ! 11 LEACHING LINE ❑ No: & Length of lines € Total length/size- FILTER BED ❑' Distance to nearest:. Well Foundation Property Line al SEEPAGE PITS ❑ Depth � Size Number si SUMPS ❑ Distance to nearest: -- Well Foundation Property Line Il ' DISPOSAL PONDS ❑. ! 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, and rules and regulations of the San Joaquin!Local Health District. 1 �` + f }(' ,. Home owner or licensed agent's signature certifies the following:. `I certify.-that;inahe 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 hir ng 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." Y � - —. s- + ' { The applicant call for all r ed in ction omplete drawing'on reverse side. Signed X f Title: Date: r FOR DEPARTMENT USE ONLY )f { Application Accepted by 3 Date 7�'/Jr Area E ` C Pit or Grout Inspection by `� + Date Final Inspection by Date Additional Comments: 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 -7104 Manteca 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE AMOUNT.DUE. AMOUNT REMITTED CK#. RECEIVED BY DATE PERMIT NQ INFO CASH ♦ EH 13-24/REV.i/a sr I�� /' ny' - } W V r f p a .-1^ .{ , EH 14-2e �✓ L L 1 .