86-138 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT it 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Cocal 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address -� L City T r a C� Lot Size 1 PM Owner's Name J im - EM i O - Address Phone Contractor H en O t n g S R r n s _ Addres License No.2qiD_8_'1_'J�_____Phone - TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 75 I SEWER LINES DISPOSAL FLD. 75 1 + 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 IX Gravel Pack i(Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Install I by Repair Work Done ❑ Type of Pump H.P. ork No,e Well Destruction ' ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ;rt TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system r e u h pe e available within 2 dt.) installation will serve: Residence_ Commercial_ Other �� Number of living units: Number of bedrooms Y j s Character of soil to a depth of 3 feet: Water tabltk - SEPTIC TANK ❑ Type/Mfg Capacity No. Compartm QtVir-N I AL HEALTH VI PKG. TREATMENT PLT:F1 - Method of Disposal `s Distance to nearest: Well Foundation Property Line II^^ LEACHING LINE ❑ 'No.Fi Length of lines 1 Total length/size 1 Vs FILTER BED ❑ Distance to nearest: Well Foundation Property Line.— SEEPAGE PITS ❑ 'Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ �: 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. 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:"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." 3 The applicant ust call for all re fired inspections. Complete dray on reverse side. Signed - .'.Date: 2--?6--86 FOR DEPARTIVIEN USE ONLY 0-7 Application Accepted by Date --2-7 Area Pit or Grout Inspection by Dat Final Inspection by Date Additional Comments: Lp // t 4)r_ M6 F ❑ Stk 466-6761 ❑ Lodi 36Sr3621 ❑ Manteca 823-7104 64J Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE, s .PERMIT`'NO. INFO + EH 4(REV.1 EH 14-2 /H 57 �� t