86-962 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i 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 Local Health District for a permit to construct and/or install the work herein described.This application is I 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. F Job Address © City (I Lot Size S PM - x Owner's Name , � "� Address'/�� G �"` `" - Phone Contracto L-- -Address A,+-71k7 4L- License No- _?, Phone _TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 'A ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE e! TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy :Type of Casing Specifications h� ❑ Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout C ❑ Irrigation _�Approx. Depth ❑ Eastern -Surface Seal Installed by Repair Work Done CI Type,of1P_ump-_ _H.P. State Work Done Well Destruction ❑ Well Diameter . Sealing Material (top 501 Depth a Filler Material-(Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION_ _REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r r.1 available within 20p_feet.)- _ Installation will serve: Residence.! Commercial_ Other Number of living units:...-_-T�_ Number of bedrooms 0 Character of soil to a depth of 3 feed, Water table depth f �- o t SEPTIC TANK ` Type/Mfg Capacity I—Ve No. Compartments "L PKG. TREATMENT PLT. ❑ i s; Method of Disposal Distance to`nearest: Well !7011 Foundation r t) Property Line LEACHING LINE L6 No. & Length of lines ` Total length/size C FILTER BED ❑ I)Marice'to nearest: Well Foundation Property Line + SEEPAGE PITS Depth 4 2 S size 33 Number 3 1 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ e` I hereby certify that 1 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." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa-tion laws of California." I The:Pplican must call for ail uired inspections. Complete drawing on reverse side. Signd Title: Date: u -FOR DEPART ENT USE ONLY n Application Accepted by Date JArea d Pit or Grout Inspection by ate Final Inspection by Data Additional Comments: F-1 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 - - - FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-241REV,I/BS) EH 1 -29