87-1880 - Laserfiche WebLink

Home Browse Search

i F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 C-) 1 L /mss City Lot Size PM Owner's Name 12L/ Address __TC- VrO 7 Z- Phone Contractor—Lu �t ddres d G C (cense No: � Phone _ -F TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE w "FOUNDATION AGRICULTURE WELL " OTHER WELL'- � PITS/SUMPS y A INTENDED USE TYPE OF WELL f PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ! ❑ Delta Depth of Grout.Seai.-- .. Type of Grout ❑ Irrigation Approx. Depth ' ❑ Eastern Surface Seal Installed by t ' Repair Work Done ❑ Type of Pump H.P, t State Work Done ► Well Destruction ❑ Well Diameter Sealing Material [top 50') Depth Filler Material (Below 50') ' } TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is _ available wi hin 200 feet.I Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Z Character of soil to a depth of 3 feef: Water table depth SEPTIC TANK Type/Mfg /�/�ii 2 Q Capacity :/2 69�-(_ M_et PKG. TREATMENT PLT. EJ . J '' ,Method of Disposal oe— Distance to nearest: Well�i"6� Foundation Property Line r LEACHING LINE 4 t N0. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS ❑ Depth 2-6-" Size r� Number tia SUMPS ❑ 1 Distance to nearest: Well l!�>c=s toundation Property Line DISPOSAL PONDS ❑ 3 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 thaf 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." I The applicant must call for all required ins ctions. Complete drawing on reverse side. Signed X C - Title: - :cs Date: "" FOR DEPARTMENT USE ONLY Application Accepted by Date 5 ` 1302 Area Pit or Grout Inspecti //' Date /J 4 Final ec by Date Additional Comme ®� L)-rrD �.�a 2G� ❑ Stk 466-6781 di 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant- Return all copies to. ental Health Permit/Services 1601 E. Hazelto .0. Box 2009, Stk., CA 95201 FEE iNFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +EH 13-24(REV. __10 GI r 1� EH 14-28 ` 61 I