86-852 - Laserfiche WebLink

Home Browse Search

4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 ,E. HAZELT ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .�t (Complete in Triplicate) Application is hereby made tothe 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` Job Address u City Lot Size I PM POOwner's Name "� "� Address �Ll. /�7f �U Phone.30 H3 f� Contractor `—' :; P Address L J '"- License No. 23 Ph on 6 s � TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ `'� SYSTEM REPAIR @' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE .;TYPE OF;WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ill: El Industrial O Open Bottom ❑ Manteca l Dia. of Well Excavation Dia. of Well Casing C�'Somestic/Private ❑i Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑'Other ❑ Delta Depth of Grout Seal Type of Grout f ❑ Irrigation Approx. Dep* o❑ Eastern Surface Seal Installed by 1 p 1I. V � Repair Work Done. IH" . Type of Pump H.P. 3 State Work Donel it f Well DestructionA O Well Diameter Sealing Material (top 50') �I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:,,-NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted'rf public sewer,is J Q �� available within 200 feet.) \1 Installation will serve: Residence Commercial_ Other Number of living unrts: i�� r NUm—er of-bedroorri"s --� •"—`"'�{ - `�- Character of soil to a depth of 3 feet: Water table depth `- SEPTIC TANK ❑ .Type/Mfg R�' Capacity' No. Compartments �! F PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �I LEACHING LINE O No. & Length of lines Total length/size Ali FILTER BED ;Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11: 'Depth Depth Size Number i SUMPS ❑, 1 Distance to nearest: Well Foundation lProperty Line J� DISPOSAL PONDS ❑.. � J I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordiriances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agerit'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 tolworkman's compensa- tion laws'of California." I� - The applicant n1vst II for a ui d inspecti S. Complete duraawing5;Z, F Signed f/YjGitle: „_ Date: ' 4 1 i I FOR DEPAR MENT USE ONLY I ' Application Accepted by Date `ti Area t I� Pit or Grout Inspection by I� Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7,104- ❑ Tracy 835-6385 *' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH f + EH EH 1 -28 IREV,t>e 6) �� =7 A• C7