87-3952 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 lit/ O/Z P k L � PERMIT EXPIRES TYEAR FROM DATE ISSUED P/e�vous (Complete in Triplicate) P frf Application is heieby 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 prdinanceMo. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin p„ Local Health Dis ict..r—,, U -„•w�,. !3 f �(. Job Address 'fH 11. 0/D i4our .2LOAD City 8OL-T Lot Size PM Owner's Name SCJIATi-iE9.0 P4C.iFIG qPEl✓iNW`,z Address 500 5.6(,U£2DAST. L.A.iCA !10011-- Phone Z} S(a-' r! x Contractor P. .EXPLP_ATit), Address P•0•U)f1101SeVILLE 5WL'cense No. Phone Rlb `770, TYPE OF WELL/PUMP: _ NEW WELL 6W NDu WELL REPLACEMENT [I DESTRUCTION ❑ ” # HOh)IToQIrJCa Li9El[.� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X $E111_ 6VZ%&.)6_S }} DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL. OTHER WELL PITSISUMPS, II INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7 Dia. of Well Casing 2" 1�<�� i [&&Vavitite,�_ Gravel Pack. ❑ Tracy Type of Casing fVc f 5T. ST-ECL Specifications 1'1 Public Cl Other I '<Delt. Depth of Grout Sea! 2-5 FEET_ Type of Grout C.Et t/6EV �- I I Irrigation 15-ZV Approx. Depth I I Eastern Surface Seal Installed by e—E-geL0,2AT-100 Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') s ' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I }- DESTRUCTION I I (No septic system permitted it public sewer is i I available within 200 feet.) Installation will serve: Residence* Commercial— Other f Number of living units: Numi her of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance;to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS C Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ` 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. 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 Cali ia." The applica mu call for uir ins tions. Complete drawing on reverse side. I - Signed X Title: /�t?.� lr��t.1 Date: _7 -� - �7 .. r � FOR CIEPART ENT USE ONLY �/] Application Accepted by v v Date � ~ 'Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return all,c pies to: vironm tal )-lealth ermit/Services 1601 Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 ILfAo IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. P + EH 13-24 iREV.i/y 51 G�(/ yf 0 —V7 07-S 9� EH 14-26 / b