87-2715 - Laserfiche WebLink

Home Browse Search

JLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-67$1 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 &lm,,e�- Ci Lot SA—fix—N) PM Owner's Name dlire;)"'_�! d AaA Phone Contractor ddress OE License N Phone TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ r 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 ,ypti ❑ Industrial El Open Bottom ` ❑ Manteca Dia.of Well Excavation ' Dia. of Well Casing V(� Domestic/Private W ❑ Gravel Pack ❑ Tracy Tyke of Casing } Specifications Public 'T 0 Other— 0 Delta Depth of Grout Seal^ Type of Grout S © Irrigation ---Approx. Dep Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump , S H.P. St a Work Do71e Well Destruction L1 Well Diameter Sealing Material (top 150'1 `~ 1 Depth Filler Material (Below 50') 'r TYPE OF SEPTIC WORK: NEW INSTALLATION'❑ REPAIR/ADDITION El .DESTRUCTION ❑ {No septic system permitted if public sewer is available within 200 feet.) . Installation will serve: Residence_ Commercial Other Number of living units: Number of bedroomst Character of soil to a depth of 3 feet: _ ___ = Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of,Disposal Distance to nearest: Well Foundation Property Liner LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line' SEEPAGE PITS ❑ Depth Size Number - SUMPS ❑ Distance to nearest: Well Foundation Property Line (� DISPOSAL PONDS ❑ l J 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.-,.-... 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."Contractors 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 for all required 'nspections. Complete Ir awing on reverse side. �. Signed Title: � Date: T– —I-Z FOR DEPARTMENT USE ONLY Application Accepted by Date ~ �� Area Pit or Grout Inspection by Date Final Inspection by Date 14 ttttttAd,,,ditional Comments: �tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Ap licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED -CK RECEIVED BY A DATE rPERMIT'NO. + EH 13.24{REV.1/861 F,�,,. "1,� 0/- EH 14-28 ��"'ttt✓✓✓ F / �3