86-655 - Laserfiche WebLink

Home Browse Search

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 .Y. (Complete in Triplicate) A, 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 1 Local Health District: ; Job AddressCity. Lot Size - PM / f v _ �f Owner's Name/ ddress' Phone ` Z 'r IContractoAddress / 74/ Licens ' o. 'iS3 Y� Phoney w TYPE OF WELL/PUMP: i� 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 ❑ Delta Depth of Grout Seal Type of Grout �,- ❑ Irrigation _L-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0, Type of Pump ' H.P. State Work Done Well Destruction ❑ WeII Diameter. Sealing Material atop 501 /. „ Depth Filler Material (Below 50'1 li TYPE OF SEPK WORK: KEW I T Olr ¢REPAIR/ADDITION ❑ DESTRUCTION C1 (No septic system permitted if public sewer is .. � available within 200 feet.) f" Installati will sere Residence Commercial Y Other f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ly Type/Mfg X' Capacity—&—b— No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Dispqsal Distance to nearest: Well 10 iv`e Foundation 2 Property Line LEACHING LINE )6 No. & Length of lines Total length/size �. F FILTER BED ❑ I Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ Depth Size _ J umber 2- SUMPS ElDistance to nearest: Well N J 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, state laws, and rules and regulations of the San Joaquin Local Health District. w Home owner or licensed agents 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 suchmanner 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,1 shall employ persons subject to workman's compensa- tion laws of California." II� The applica must call for a req ' d inspe ions. Complete drawing on reverse side. Signed X IN Title: Date: FOR DEPARTMENT USE ONLY r rior tion Accepted by Date 8 Area Gtout Inspection by ., L�= Date ( of uL spection by Date Additional Comments: El Stk 466-6781 ❑ L di 369-3621 ❑ Manteca 823-7104. ❑ Tracy 835-6385 Applicant- Return all copieslio: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 PEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO n CASH / �y +,EH 13-24{REV.1/H 5t Iro, EH 1428 Is ~