87-3442 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 IPERMIT 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.,,.. ' A �, Job Address l r + rr 11 11,� Lot Size PM '�o � �TT�� 1yAA '' r 4 Owner's Name Address Phone Contractor_\N tLVtJA,l' L ) Address ?)sf) k-0-. C-�---'4A + License No. Phone TYPE OF WELL/PUMP; NEW WELL,1-1 WELL REPLACEMENT ❑ DESTRUCTION 171 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ °? DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL .:1 PROBLEM AREA; CONSTRUCTION SPECIFICATIONS 7 ❑ Industrial ❑ Open Bottom y ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private, Y ❑-Gravel_P-ack ❑rTsacy - ^m Type of Casing _,Specifications_-_- - — M Public Cl Other t ll Delta: Depth of Grout Seal Type of Grout I I Irrigation f _.-Approx,1Depth ll Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done I Well Destruction ❑ Wel! Diameter Sealing Material Itop 501 F F` } Depth Filler Material (Below 50'1 ! TYPE OF SEPTIC;WORK: NEW-INSTALLATION m'_REPAIRJADDITION l- STRUCTION l I Wo septic system permitted if public sewer is I �Commercial available within 200 feet.l Installation will serve: Residence Other i '-- -F Number of living units: . 'Number of bedrooms Character{of soil to a depth of 3 feet:".I "^ Water table depth SEPTIC TANK ❑ Type/Mfg: CL`W(f 011; �' ,Capacity No. Compartments PKG. TREATMENT PLT. ❑ Y _ 3 " r� - � Method of Disposal Distance to nearest: Well—��.— Found J__ Property Line 1 � i- . r LEACHING LINE } L9�JtVo& Length of lines .7 Total length/size 1 FILTER BED ❑ distance to nearest: Well Foundation —]�-_� Property Line fC)'�� r �� i t SEEPAGE PITS IY�pepth, .'ck as Size Number SUMPS L� Distance to nearest: Well 1 ZSO' Foundation Property Liner DISPOSAL PONDS 0 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, anc, rules and regulations of the!San Joaquin Local Health District. { Home owner or licensed agent'ssignature certifies the following:_"I certify that in the performance of the work for which this permit is issued, I shall nor employ any person in such man`ne'r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ca I e following ertify that in the' rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa{ tion laws o liforni .' r 1 The applicant t II for-al to ompl a drawing o averse sid ` �s 4 Signed X Titre: Date: F EPARTiNENT USE ONLY p s Application Accepted by _�{ ��t�� _ Data Area Pit or Grout Inspection by _ Date Final Inspection by Data - Additional Comments: a�Bru. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. I + EH13-24{REV.i/851 D� QA&O I EH 14-26 ��/