87-151 - Laserfiche WebLink

Home Browse Search

N ' APPLICATION FOR.uPERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT II 1601 E. HAZELTON AVE., STOCKTON, CA li Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED II (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for 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. , / II Job Address • rLQ Al 4W O Lot Size-29:� X 12 y PM y �J Owner's Name /"a,�7` 1 �ff �, � Address 1 5 5 `�"- $VfAhone .34 tl q Contractor's Name License No. z/Y Phone ie 1 - ` TYPE`OF WELL/PUMP: 6 NEW WELL Xj� r WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Z;.� SYSTEM REPAIR ❑ 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 ❑ Industrial en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing &-ifomestic/Private ❑ Gravel Pack ❑ Tracy d Type of Casing; Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Q T of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 17Type of Pump r H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 501 ` Deptl Filler Material.(Below 50') TYPE OF SEPTIC WORK: NEW'INSTALLATION ❑ REPAI_R_/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is (A available within 200 feet.) Installation will serve: Residence'` C mmercial,`_ Other _ ~�- L_, 'I Number of living units: Numbe ofbedrooms G Character of soil to a depth of 3 feet: " Water table depth ` i)SEPTIC TANK ❑ Type/Mfg Capacity— M1 No. Compartments PKG. TREATMENT PLT,. ElI� 'Method i Disposal F Distance to nearest: Well Foundation Property Line i _ LEACHING LINE ElNo. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation '' Property Line SEEPAGE PITS ❑ Depth Size ==- ---- ;Num�ber SUMPS ❑ l stance to nearest: Well Foundation Property Line w DISPOSAL PONDS ❑ .II. 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 eompensa- tion laws of California." The applicant mu call for all required inspections. C mplete drawing on reverse side. Signed X -� I Title: Date: iiFOR DEPARTMENT USE ONLY Application Accepted by I, Date Area ii /J�� ,' a Pit or ro Inspection byTn —! Date k2- Final Inspection by Date Additional Comments: i ❑ Stk 466-6761 ❑ Lodi 1 369-3621 ❑ Manteca 8'23-7104 ❑Tracy. 835-6385 f Applicant- Return all copies to: Environmental Health--PermitlServiees-160;-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f i �- a� FEE INFO AMOUNT DUE AMOUNT_REMITTED CK _RECEIVED 6Y DATE PERMIT`NO. CASH ,-.. e .. ,,0 ,,Y\ 9-7-X51,,. i + EH 13241RE7I.10!831 . j >13Q "� 87-15 1 EH 14128