86-1289 - Laserfiche WebLink

Home Browse Search

• a APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAMILTON{AVE., STOCKTON, CA , Telephone {209) 466-6781 .PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED (Complete'in'Trililica'te) 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. 1 Job Address t`115 t`City M1 } Lot Size ' PM Owner's Namer X1 Address _ 7 , Phone =rr~ N. -re Contractor i Address(99003 i"AlA - L ense N1-21 � �� ' F'hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT, F DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ - %*OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. ;LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ In stria) ❑ Open Bottom ❑ Manteca # Dia. of We'll Excavation Dia. of Well Casing I omestic/Private ❑ Gravel Pack ❑ Tracy Type of�Casing Specifications ❑ Public ❑ Other r ❑:Delta Depth of Grout Seal - Type of Grout ❑ Irrigation ---Approx. Depth ❑"Eastern Surface Seal Installed by j 1 Repair Work Done 9� Type of Pump. H.P._1 State Work Done f � Well Destruction t ❑ �Well Diametb_rl Sealing Material {top 50') ; Depth—- Filler Material {Below 501 ` V TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �ti t available within 200 feet.). 1 N�lnstallation will serve: Residence Commercial_ Other f x Number of living unitsi Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well foundation Property Line 4 LEACHING LINE ❑ No.-&-Length of lines ''"Total length/size-_7n"T-" FILTER BED ❑ Distance to nearest:" -Well-ma y Foundation Property Line F ! SEEPAGE PITS — ElDepth ,•-. Size m _ . Number— SUMPS ❑ Distance to nearest: Well Foundation Property Line DISP05AL PONDS ❑ a "� I hereby certify that I have prepared this pplication 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 District. i 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 i 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." 1 The applicant ust all for all require spe i s. Complete drawing on r side. 1 Signed - Title: _� - - Date: r `"'^��-��---•-�� '�, - —""�*�""""'°'FOR DEPARTMENT USE ONLY �'" � Application Accepted by Date U Area" Ili- �- i t o-2q-�6 A Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Ar A`/ ❑ 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 FEEAMOUNT DUE ' AMOUNT REMITTED RECEIVED BY DATE PERMIT "NO. ' INFO — -.EH 13-24(REV,1/0 5) EH 1426