86-719 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT O 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 IXIPERMIT 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 R I u'^ Ci `v Lot Size PM Owner's Name LE "Address J�r �TTI��- � Phone '5119-4710 :, Wt�.sD0 mss^ =r3Y� dog Contractor I�10 � Addres d License No Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ !f PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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,C_asing' Specifications t ❑ Public ❑ Others F ❑ Delta Depth of Grout Seal Type of Grout j ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ftop 501 Depth Filler Material (Below,501-r, TYPE OF SEPTIC WORK: NEW INSTALLATION ❑.REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence)_ Commercial Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: „ter Water table depth SEPTIC TANK ❑ Type/Mfg - Capacity�`''E No. Compartments } PKG. TREATMENT PLT. ❑ . _A Method of Disposal Distance to nearest:—Well—Foundation Property Line LEACHING LINE ❑ .No. & Length of lines �Jy T9ta1 length/size 1d9_91F FILTER BED Distance to nearest: well X50 f Foundation/�Jr�f 'Property Line SEEPAGE PITS ❑ Depth i Size I Number— l I SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ Yl 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 Districts - Home owner or licensed agent's signature certifies the following: "I certify that in the performance-df the work for which this permit is issued, I shall not employ any person in such manner as to:become subject to-uvorkman'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 applica mu r all r ire inspections. Complete drawing.on`re arse si Signed Ti Date: FOR DEPARTMENT USE ONLY Application Accepted by Data 30 Pit or Grout Inspection b Date�cpmsp 1 Final Inection Date7,?X6 Additional Comments: ea 4 sf { J ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 93201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY - DATE PERMIT'NO. 1 INFO CASH + EH 13-24(REV:s/a s) Q f :��+ Tjb—771 q EH W26 I - �7