86-754 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT l t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601.E. HAZEL T ON AVE., STOCKTON, CA f Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED • ,y�. , : . {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 `7 7 9d + rC�l-LfrO Ai/A A L1.0 � ` k City '�_��y _ Lot Size PM `Owner's"Name'A -,igL.eT=..� /C /� Addressz� -� Phone Contractor 1.81/f7R ' ^~ , �{j�@r'�`Address• O.�ifJ.;.L - iL1•--• - L.icense No. ��Phone"' - TYPE OF WELL/PUMP: NEW WELL ❑,.- "` WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ SYSTEM REPAIR ❑ '0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r.---FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL 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 is ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout f ❑ Irrigation ---approx. Depth ❑ Eastern Surface Seal Installed by l Repair Work Done ❑ Type of Pump H.P. State_Work Done Q Well Destruction Cl Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 " TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION D_(No septic system permitted if public sewer is ✓J { available within 200 feet.! Installation will serve: Residence_ Commercial_ Other . { Number of living units: _/_ Number of bedrooms Character of soil to a dept of 3 feet:_ /�L� +,Y1 - ` Water-table depth SEPTIC TANK Type/Mfg Capacity 4 lf,�p0 — No. Compartments 'Z— PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well 1099-rt Foundation /D Property Line L� LEACHING LINE No. & Length of.lines 1 Total length/size a -'t- F!L' ERBED ❑ Distance to nearest: '">, Well& Foundation_� !'�, Property Line SQ r = Y � 4,']..�..- ie, yet SEEPA�CsE:PIT$ �f7_ - Dept- ti' "�-` � Size,,r Number SUMPS 1=7 Distance to nearest:i 'Well' Foundation Property Line DISPOSAL PONDS ❑ 4 I hereby certify that I have prepared this application--and that the work will be done in accordance with San Joaquin county ordinance`s, state laws, and K ' rules and regulations of the San Joaquin Local Health,District. 1i # 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." t The applicant must call for all required inspections omplete drawing onrereverse siside, 4 Signed Title: Date: , FOR DEPARTMENT USE ONLY Application Accepted byDate Area a I Pit or Grout Inspection by Date Final Inspection by Date. I Additional Comments: ❑ Stk ,466-6781 171 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Service's 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.. + EH 13-24(REV.I/U al EH 10.28