87-2272 - Laserfiche WebLink

Home Browse Search

ti ' APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District: Job Address i� C✓ 1 �l �1 City y Lot Size r u4�. PM , I Owner's Name �fe.�� Address r Contra t /• ,�ar L�f / Address �rLicense No 06 Phone TYPE OF WELL/PUMP: NEW WELL JK WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 5( SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE-TO=NEAR EST=SEPTIC-TANK 400 �" SEWER-LINES i`" DISPOSAL FLD.-��' '. PROP. LINE �� 1[/A j .FOUNDATION : 's„01 _"AGRICULTURE WELL "' OTHER-WELL' PITS/SUMPS _ 1 T INT�NDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E ❑,Indu'strial ❑ Open Bottom ArManteca Dia. of Well Excavation Dia. of Well Casing b A'Dome -stic/Private Gravel Pack ❑ Tracy, Type of Casing iV C_ R ecifications�� f FI'Public Flit h ./o,J� f�'Re4tar� � Depth of Grout Seal �"Type of Grout � f I Irrigation Approx. Depth'` I ) Eastern_ Surface Seal Installed by • 1 '� --- Repair Work Done ❑ Type of Pump �.y,P.. ., State Work`Done'- ' '•U'�r `• � tpublic Well Destruction C] Well Diameter ~ f Sealing Material (top 50'IDepth Filler Material (Below 50'1TYPE OF SEPTIC WORK: NEW INSTALLATION ( ) REPAIR/ADDITION1 1 DESTRUCTION-(7-INo,septic system permiJisavailable within 200 feetInstallation will serve: Residence; Commercial OtherNumbrer of living units: Numb_er of bedroomsCharacter of soil to a depth of 3 feet{ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ i 3 Method of Disposal g ( Distance to nearg'st: Well, y�. foundation Property Line C".. LEACHING LINE M �No.A-Length of-lines Total length/size FILTER'BED ❑ Distance�to nearest: Well Foundation Property Line �� , SEEPAGE PITS fl Depth Size Number SUMPS 1-1 - Distance to nearest: Well Foundation Property Line ;. . .'.i DISPOSAL POND "'" E -� ; .,�❑ �' / - I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,.and 'L rules and regulations of the San Joaquin Local Health District. t . 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 California." The appEican st call or all required inspe tions. Complete drawing on reverse 'de. Signed X �' Title: ' Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 4 Area Pit or Grout inspection b �`?"1 Date r�L6 Final Inspection by Date Additional Comments: ❑ Stk 466-67131 ❑ Lodi '369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave.,, P.O. Box 2009, Stk., CA 95201 FEE INFO AkJN E AMOUNT REMITTED CASHRECEIVED BY DATE PERMITND. EH 13-24{REV.i/n 51 / �® �y� 7 -