86-804 - Laserfiche WebLink

Home Browse Search

A APPLICATION FOR PERMIT w SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA - Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Trjplicate) " 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-Pounty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.} �. I' los--;?20 Job Address /�✓ ,v � � �Cd City I-P-JLot Size Iy A6R5;• PM ' 6 Owner's Nam, _60-11i Address / QI�.N. ¢0V57DAJ /JJJF Phone q 2-Z_ - Contractor' i�, Address��a "w� N-�4Y License No;a5'3�-� Phone V�"q"�'a' TYPE OF WELL/PUMP: 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 N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C7 Public ❑ Other ❑ Delta Depth of-Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump H.P. State Work Done y Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below .5W) 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 x Commercial_ Other f of Number of living units:_Z_ Number of bedrooms N C P f � � l Character of soil to a depth of 3 feet: / ��21�P�+411i Water table depth j SEPTIC TANK 'C� Type/Mfg -?A RRISA 42W Capacity j 2No. Compartments k PKG. TREATMENT PLT. ❑ rte, Method of Disposal Distance to nearest: Well �0j-t Foundation l© Property Line -S � i t LEACHING LINE ❑ No. & Length of lines Z X 1d0 Total length/size Zoo ° FILTER BED ❑ Distance to nearest: Well Foundation /©' Property Line .S SEEPAGE PITS ❑ Depth Z- Size 253 Number r SUMPS ❑ Distance to nearest: Well.41� Foundation /0 Property Line-- DISPOSAL PONDS ❑ 1 k L t 1 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 Calif ia." pf .VL_drq t/E The applicant ust call all r e nspe ions. Complete drawing on revs side. / Signed Title: [ -- J Date: //_- FO DEPARTMENT USE ONLY _ r Application Accepted by Date Area Pit or rout Inspection by ,,�- .. Data -18-6 C Final Inspection by Date Z Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton.Ave., P.O. Box 2009, Stk., CA 95201 fl CK'T—FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. + EH EH13-24(REV.1/B:s) _7°C) p� 1�� (�� To l r