86-1033 - Laserfiche WebLink

Home Browse Search

A APPLICATION FOR PERMIT 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. _ r 4a Qob-Address n City Lot Size PM Owner's Name ss Phone Ik actor en\se No. t � oneContrerss r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 Casing Specifications ❑ Public ❑ Other f! ❑ Delta Depth-of Grout Seal - Type of Grout 5 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by rs Repair Work Done ❑ Type of Pump 'tet '� H.P. State Work Done Well Destruction ❑ Well Diameter `3 Sealing Material (top 509 Depth,- ` Filler Material (Belo 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ lNo septic system permitted if public sewer is �� _• �. _.__,_,. i __ t._ __ - available within 200 feet.I, Installation will serve: Residence °' Commercial_ Other t k ! Number of living units:: ^. Numbe►of bedrooms Character of soil to a depth feet: i ,. Water table depth SEPTIC TANK Type/Mfg "� Capacity No. Compartments PKG. TREATMENT PLT. ❑ j'1 % rr Methodfof Disposal t` Distance to nearest',`: Well n ': Foundation Property Line ; LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ElDistance to nearest: 1 Well. rFoundationLl Property Line SEEPAGE PITS Depth Size r Nunier �' Property Line MP ❑ Distance to nearest: Wei�`_ F � Foundation DISPOSAL PONDS 1-1 _ r 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-Distdct- 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:.".l 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. Theapplicant' us or� I re Y ire i spections., Complete drawing on >s ""'fde: Signed Title• Date: .f �r F DEPARTMENT USE ONLY Application Accepted by Date r Pit or �tlnection b to � Final Inspection by ate ` Additional Comments: ❑ Stk 466-6761 ❑ 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 r i FEE INFO AMOUNT DUE// AMOUNT REMITTED CASH CK RECEIVED BY ND DATE PfE_RMIfT NO. + EH 1324(REV.)/asJ , q/ � � •� NU !d'y(0_33 EH 1428