87-929 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—i ON AVE., STOCKTON, CA r 0 Telephone (209) 466-67$1 f L f //0 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUgD t t " (Complete in Triplicate), Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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. x ; Ace JobJob Address) L � •"p"�' "`'� city � / Lot Size 0 , s PM r Owner's Name �� if �` - Address —� 2� � '�Q�'e. � Phone y r r Contractor's Name' `� License No _ r Phone {7- TYPE OF WELL/PUMP: _ J. F NEW WELL 11WELL REPLACEMENT ElDESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK`' f SEWER LINES, DISPOSAL FLiD. PROP. LINE FOUNDATIfa;� AGRICULTURE WELL OTHER WELL.' PITS/SUMPS _ INTENDED USE TYPE OF WELLS PROBLEM AREA CONSTRUCTION SPECIE#CATIONS C7 Industrial, ,;�, ❑ Open Bottom .. �,T❑ Manteca .. Dia. of.Well Excavation _.' _ —Dia. of.Weil1-1 'Casing Y D�D.omestic/Private. ❑ Gravel Pack ❑ T,racy Type of Casing Specifications �.. ' i ❑ Public [-] Other ' ❑ Delta'%,"k Depth of Grout Seal Type of Grout i ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by. di �,Repai+Work Done'' ❑ Type of Pump H.P. State Work,�Done ` a WeIlryDestruction ❑ Well Diameter Sealing Material (top Depth ' Filler Material•(Below-50')+ TYPE:OF`SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION ❑ tNo saptic system permitted if public sewer is available within 200 feet.) Installation will serve: Re Re Commercial_ Otlfe{ �� Number of living units: Number of bedroo Character of soil to a depth of 3 feet: W6ter table depth_ .- SEPTIC TANK Type/Mfg Ca aci �N Na. Compartments � PKG. TREATMENT PLT. ❑ °• { ..Method of Dispo I — Distance to nearest: Well!/+V Q_ Fouridatiori P'ropert�i Line; LEACHING LINE " No. & Length of lines �. Total iengthf§rz � �� FILTER BED ❑ Distance to nearest: Well O r- Foundation Props y ine SEEPAGE PITS ❑ Depth Size N mbar 1 SUMPS � Distance to nearest: Well, 446undationu, ` ' Property Line DISPOSAL PONDS ❑ t �""� •# � ,,; 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, and, rules and regulations of the San Joaquin Local Health District. µ 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 ,�I 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 followin :"I certify that in the performance of the work for 1ltirhich this.permit is issued-0 shall employ persons subject to workman's compensa= tion laws of Califor ra." �r7 =The applica m r all i ed inspections. Complete drawing on reverse side'` s ^' Signed Title:^� � Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ~' � F Area Pit or Grout Inspection by Date Final Inspection by �Y� Date _ , Additional Comments: f ' ❑ Stk 466-Ml ❑ Lodi-369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEECK NFO AMOUNT DUE AMOUNT REMITTED. GASH RECEIVED BY DATE PERMIT"NO.' c + E H1 3-24[REV.101831 EH 14-28 ► 1