86-1268 - 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) 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. [� Job Address S Ci Lot Size ' L -- PM + /<, Owner's Name � Address Phon ,t Contractor Address icense No. `7 7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ w SYSTEM REPAIR ❑ OTHER ❑ ASI_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ In f" "t7 Open Bottbm 5tl ❑ Manteca Dia hof=V4lefl fxCavatiori'�="= Dia, of Well Casing Domestic/Private r,.! ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I { w Type of Grout ❑ Public ❑ Other ❑ Delta Depth of Grout Seal YP ❑ Irrigation ---.--APProx [ h"*�'❑°Eastern '' , , Surface S�Ilstalled by ' H.p. �Sttaate Work Done Repair Work Dane`j❑ Type of Pump• ' - ,, Well Destruction -❑"`'Well-Diameter Sea ig MateftNtop 50') ' DepthFiller Material i6Iow 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION O DESTRUCTION:❑.{No septic system permitted if publicsewer is S available within 200 feet.-)"`- Installation will serve: Residence X Commercial_ ther - � .4,� r Number of living.units: Number of bedrooms ` Character of soil to a depth of 3 feet: 1 "ter tattle depth ` SEPTIC TANK ❑ Type/Mfg Capa No. Compartments PKG. TREATMENT PLT. C1 Method of Disposal I Distance.to nearest: = Well �a Foundation Property Lire Total len th/size LEACHING LINE � No. & Length of lines � 9Y. FILTER BED El Distance to`nearest:—-Well" Foundation Property Line ` SEEP/�GE PITS ❑ Depth Size Number -w-,�... . a SUMfS-'"- ❑ Distance to nearest: Well Foundation Property Line mor DISPOSAL PONDS ❑ 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 nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:""I ify that in th rformance of.the work for which this-permit is issued,I shall employ persons subject to workman's compensa- I tion laws of Caiiforni The applicant.m I for quir i pections. Complete drawing on reverse stile.. -14-S6 Signed Title: Date: — FOR DEPARTMENT USE ONLY' } W�.:fin' t � ._ � a % Application Accepted by r Date A L� Area { Date Final Inspection by Date Pit or Grout.Inspection by ` - Additional Comments: �� "�� Av //—If ❑ Stk 466-6781 E3Lodi 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 CAMRECEIVED BY DATE PERMIT'NO. INFO S ` I + EH 13-241REV.t/a51 ��- EH 1428