86-22 - 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) 14 d U C-4 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. '7 Job Job Address __ �+ I y/� �____. City Lot Size PM l III Owner's Name —Z V ��C, Address Q +~ Phone + 5 5 -q-4,r Contractor's Name /► MA-C-1 icense.No. ! S( o _. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTIO ' ' PUMP INSTALLATION ❑ SYSTEM RE AIR ❑ 0TH 13 ` DISTANCE TO NEAREST: SEPTIC TANK f6 SEWER LINES 1410 '� DISPOSAL FLD/! 6 PROP. LINE /Oa l FOUNDATION 1:1 — AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z Industrial Q ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ` Dia. of Well Casing ❑ Domestic5,pni,te )W Gravel Pack ❑ Tracy Type of Casing Specifications ,A ❑ Publics, ❑ Other ❑ Delta Depth of Grout Seal 5 O ` Type of Grout p of62/i ❑ Irrigation j�Approx. Depth C1 Eastern Surfac Seal Installed by c C_ ' i Repair Work Donef ❑ Type of Pump � M.P. � State Work Dane �.r, G �JrGs? Well Destruction) . 17Well Diameter Sealing Material {top 50'} n` Depth Filler Material (Below 501 - PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is j available within 200 feet.I j InstallationNe: Residence— Commercial_ Other Numberof living units: Number of bedrooms Character of soil to a depth of 3depth- . SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments } PKG. TREATMENT PLT. ElMethod of Disposal Distance to nearest: Well oundation Property Line LEACHING LINE ❑ No. & Length of lines .. �Iength/size_ FILTER BED ❑ Distance to nearest: Well Foundationtt % SEEPAGE PITS ❑ Depth Size Number SUMPS i ❑ Distance to nearest: Well Foundation \. f Property Line DISPOSAL PONDS ❑ 8 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 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." The applican II for all required ' pectin . Complete drawing on reverse side. ` Signed Title: T'r e s Date: FO�DEPART T USE ONLY Application Accepted by vv Date _� ��v� Area Ph o Grou Inspection by Date ` v Final Inspection by Date ff 0 Additional Comments: _ ❑ Stk 466-6761 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 Applicant- Return MIX to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE ' + INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'`NO. C7 + EH13.24 4REV.10183) EH 114-28 - f•