86-611 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT ! 1601 E. HAZE.--1 ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) e 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ,;W -3 Co A5; �,e*' J1,S City Lot Size PM Owner's NameAddress Phone Contractor_L4Fc=_, W L ALLaddress License_No. y.fin Phone 56L-)J, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ '' DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM'REPAIR ❑ "` .OTHER"❑ . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .DISPOSAL FLO. yPROP. LINE ,_ PUNDATION l' ► AGRICULTURE WELL: '" OTHER WELL PITS/SUMPS � x INTENDED USE! TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E ❑ Industrial l :-, ©.Open Bottom ❑ Mantec`a 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 • ---Approx. Depth ❑ Eastern Surface Seal Installed by 3 ' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50')' Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 available within 200 feet./. Installation will serve: Residence ✓Commercial_ ther f Number of living units:1— Number of bedrooms i Character of soil to a depth of 3 feet: ��n©�i Water table depth SEPTIC TANK r�/Type/Mfg �T-l`7 h4 'LY" t' `r`jCapacityQ� No. Compartments a-- s :: PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: I Well Foundation - rP.roperty Line 1d�t LEACHING LINE 41-90.-& Length of lines `� '�� Total length/size 76 " FILTER BED ❑ Distance to nearest: Will F)V Foundation 3 O property Line E SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well 'rFoundation Property Line )OOf DISPOSAL PONDS ❑ �' j -»� '1`t "' �� 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:---�� 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 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 /avi- 0 o ` ornia." VThe plicant us II fora requi d inspe t ns. mp a raving on r arse side. ,A f Signed Xtie: Dater FOR DEPARTMENT USE ONLY Application Accepted by Date Ara Cl Pit r Grout Inspection by _ Datenal Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ 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- - - -- •--T--- w - - - -.T"__ ...fE__ - - INFO AMOUNT DUE AMOUNT RE 1T G !t' RCC�.IV�ED�BY 1 1DAlTE PIERMIT NO'T + EH 3-24 EH 1428(REV. /s5) ©�4 S1p�b- �--'\ �( V , I•