86-391 - 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 (Complete in Triplicate); r s 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 l'l-// OR,F's 3.. city. Lot Sire -PM Owner's Name-. 1 -"Address _ Phone 11? Contractor // Address B44ellaW ege,0 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WEXREPLACEMEN7,,❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR '❑ - OTHER ❑ ` DISTA ICE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION "AGRICULTURE1 f -_ WELL I .t- 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 ,VDon stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrig Ition --Approx. Depth , ❑ Eastern Surface Seal Installed by , Repair Work Done ❑ Type of Pump "P H.P. ,1 State Work Done!C&eAe94,z r1lP Well Destruction ❑ Well Diameter Sealing Material (top 50 G(J/Ti51 Alew! lrror0 peptFl _ Filter Material (Below 501 TYPE OF SEPTJC WORPNr_NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ,# I` -j `available within 200 feet.)} Installation will serve: Residence— Commercial ` Other r Number of livin units: Number of bedrooms r y f Character of soi to a depth of 3 feet: _ Water table depth �SEPTIG�TANK ❑ Ty /Mfg� � Capacity No. Compartments r0KG. TREATMEN I PLT. O >4 Method of Disposal ? Distance to nearest: We Foundation Property tine LEACHING LINE "[-INo & Length of lines Total length/size 1,FILTER BED ❑ . Distance to nearest: Well Foundation Property Line EEPAGE PITS` ❑ Depth Size Number _ SUMPS f �._ -��-O—Distance to nearest: Well Foundation Property Line DISPOSAL PO�NiOS''-ip t'-• I herebyicertify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 rules and regulations of the San Joaquin Local Health District. - Home owner or licensed agent's signature certifies the following: "1 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." I The applicantust ga III r all required inspections. Complete drawing on reverse side. _ Signed X Title: r FOR PARTMENT USE ONLYt�r ,,.. Application Accepted by Date I ' Area !Y« Pit or Grout Inspection by Data Final Inspection by =� T! Dat�� k Q A itionpl Comments: 1 tk J466-6781 . ❑ Lodi 369-3621 El Manteca 823-7104 w, EJTracy 835-6385 M Applica - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA952 t FEE AMOUNT•DUE' AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + ER 13-241REV-,i1151 --57 �"~' - / ER.14-28 ✓ �(Zrj/ � �"�' �3p'r