86-1334 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .i (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 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... < Job Address 1J yl/ /V• i.G�/211�L C(.. _ V _ City Lot Size PM I� Owner's Name Ic Address �"Pho`ne' Contract Address e License No. 2�a(' Phone « 13"SS TYPE OF WELL/PUMP: I� NEW-WELL_C1 WELL REPLACEMENT Cl DESTRUCTION ❑ PUMP INSTALLATION 0' SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK XSEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS } INTENDED USE TYPE OF WELL PROBLEWAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ! ❑ Open Bottom EI Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private F1 Gravel Pack ❑ Tracy Type of Casing Specifications ❑rPublic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation t --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work done❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter', Sealing Material (top 50') Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units:�.� Number of Brooms Character of soil to a depth of if 3 feet: J Water table depth 75 SEPTIC TANK JIKType/Mfg~ Capacity 06 No. Compartments PKG.EATMENT PLT. ❑ ', Method of Disposal i Cr Distance to nearest: -w Well Foundation�- Property Line S:_ LEACHING LINE No". & Length of 1 �"� y"' 0' Total length/size Y FILTER BED ❑ Distance'to nearest: Well ./06` 1' Foundation_.._/_Q Property Line__ S SEEPAGE PIT S 2r Depth _ f _Size j+ Number SUMPS " ❑ Distance to nearest: Well' 0�� Foundation 16, Property Line DISPOSAL PONDS ❑ IN 4 I hereby certify that I have prepared this application and that the work will be done iri accordance with San Joaquin county ordinances, state laws, and rules and-regulations of the San'Joaquin Local Health District. �1 Home'aw6er or licensed agent's signature certifies the following: "I certify tthat 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 applicant must call for eq 'red inspections. Complete drawing on reverJsepde _4 Signed Date: 7° Title: �/j . Oct9 ( FOR DEPARTMENT USE ONLY Application Accepted by Date RID /4- 9 Area Pit or Grout Inspection by I DateD Final Inspection by Date 9 Additional Comments: �k ❑ Stk 466-6781 ❑ Lodi 1369-3621 ❑ 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 C INFO ASH RECEIVED BY DATE PERMIT NO. t f 1 I�+ EH 13-21[REV.t J e 51 EH 1428 �i