87-2455 - Laserfiche WebLink

Home Browse Search

i CL T APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL-HEALTH DISTRICT. C 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 ' ` Telephone (209) 466-6781 � �v �1��yOfrlAPOP- 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N QL 1-- {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 a ' is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wail/pump and the Rules and Regulations of the San�� I Local Health District. Joaquin • ,1 fit ,c -.. Job Address IT11�1 .l- tf City E Lot Size PM Owner's Name &1w g I AJ A _address Phone Contractor Address License No. Phone (�TYPE.-OF WELL/PUMP: NEW WELL ❑ WELL f3EPLAtyEM_ENT,❑ DESTRUCTION b ' PUAP INSTAL`LATION'❑ v t' -x -� SYSTEl 66PAIR ❑ e " OTHER ❑ i .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 R ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well ExcavationI Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1." Specifications ❑ Public " ❑ Other ❑ Delta Depth of Grout Seal � �-.v�4 ❑ Irrigation _q � Type of Grout t " pprox. Depth ❑ Eastern Surface Seal Installed by-� �---T ► Repair Work Dane ❑ Type of Pump H.P. State Work Done I Well Destruction 1-1 Well.Diameter Sealing Material (top 5D 1 ` r (� Depth Filler Material (Below 50')-• �J I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is t i available within 200 feet Installation will serve: Residence— Commercial—,Other. - �� :}f 6 Number of living units: I Number of bedrooms; Character of soil to a depth of 3 feet: -Y±Yr Water table deptho ,t SEPTIC TANK ❑ Type/Mfg 1 _CapacityI No. Compartments i PKG. TREATMENT PLT. ❑ I �-- t Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of.lines Total length/size ' FILTER BED ❑ Distance to nearest: _- Foundation t Property Line_ 1V SEEPAGE PITS ❑ Depth Size Number ? ` SUMPS ❑ Distance tor-near est: --------- Well Foundation Property Line DISPOSAL PONDS ❑ ! hereby certify that I have prepared this applicati6h,and:th'at the work will be done in accordance with San Joaquin county ordinances, state laws, and ffi ' rules and regulations of the San Joaquin Local Healt 'District. , y 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." } The applicant m st c ll f r all reAVired ins a ' _ � `` inspections. Com to drawing on reverse side. Signed 4 d Title: ' Datb ��,SIq f e. FOR DEPARTMENT USE ONLY Application Accepted by M Date Area Pit or Grout Inspection b Date Final Inspection by Da , Additional Comments: i ❑ Stk 466-6781 ❑Lodi-369=3621 �—0,Mantecb -7104" a Y C1 Traoy 83x6385 Applicant- Return all copies to: Environmental Health Permit/Services' 1601 E. Hazelton.A%4 P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO y� RECEIVED BY DATE PERMIT''NO." , + EH13-24fREV.I/as) EH 14-26 _ „ S 24