86-1567 - Laserfiche WebLink

Home Browse Search

i I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �(v 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES'I .YEAR"FROM DATE ISSUED" { E {Complete.)n Triplicate), ...` ,. ., v<.skyl�fat .. ',r,J�. • '� ,i .4 -ft- .• 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 a made in compliance with San Joaquin County Ordinance No.549 for sewage or No:1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. PIr Job Address r� City Lot Size f Owner's Name = Address x � �� r��— Phone `�� A Contractor Address License No.A&M Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL EPLACEMENT EJ DESTRUCTION ❑ PUMP INSTALLATION ❑ � ,� SYSTEM REPAIR ❑, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD. PROP. LINE HER M 'PITS/SUPS FOUNDATION ' AGRICULTURE WELL OTWELL . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f 13 Industrial ❑ Open Bottom 1-1MantecaDia. of Well Excavation Dia. of Well Casing f a"""" a of Casin """'"� Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typ_.__..., g + ❑ Public ❑ Other ° - ❑ Delta ;FSuffire Depth of'Grout Seal Type of Grout r1" ❑ PubliIrrigac --Approx. Depth ❑ Eastern 'Seal Installed by _ E V" Repair Work Done. ❑ Type of Pump H.P.— State Wor I Dome 6 Well Destruction ❑ Well Diameter Sealing Material(top 60') k Depth . Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ .OESTRUCTION (No septkc system permitted if public sewer is I, ' I r available within 200 feet.) Installation will serve: Residence, Commercial—J Other Number of living units: Number of bedrooms f F Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capaty No. Compartments PKG, TREATMENT PLT. ElMethod of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE 11 No. & Length of lines7 'To'tal length/size FILTER BED ❑ Distance to nearest: Wel Foundation Property Line F l SEEPAGE PITS ❑ Depth Siz Number s< SUMPS ❑ Distance to nearest: Well Foundation Property line DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,I'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 i ued, 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:"Icertify 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." S, The applica ust call a I qu' d ' pe ' ns. Complete drawing on reverse side. +i Signed Title: Date: DEPARTMENT USE ONLY !' Date a Application Accept@ byO Pit or Grout Inspe an by Date Final Inspection by Date f Additional Comments: ' t ❑ Stk 466-6781 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE' PERMIT''NO, k INFO + EH 13-24(REV.1/85) - -�` EH 14-26 - - - - -