86-1533 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA - Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 //3>'ta u/ 00 City Lot Size /0 PM Owner's Name//UJ., �!/Ute. ,/alt Address .]I/ !V. t1�� Phone ?13 q `ls Contract [A Address <!?07C 707 �r License No.V�$aa(- Phone (o —51 0S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca 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 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler M (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ADDITI EY DESTRUCTION ❑ (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence r Commercial_ Other�/ alQ Number of living units: I Number=drooms sJ r Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK lfl Type/Mfg CapaciI No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal O� Distance to nearest: Well Faundation Property Line p(� LEACHING LINE El--No. & Length of lines 1�1 ` - Total length/size >< FILTER BED ❑ Distance to nearest: Well Foundation��O Property Line ~rte SEEPAGE PITS — Depth " le Size ,.�3' x o� Number r SUMPS U3/Distance to nearest: well 06f=t Foundation Property Line y� DISPOSAL PONOS ❑ 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 applicant st call for equ' d inspections. Complete drawing on raver ide. Q Signed Title: �� Date: U FOR EPARTMENT USE-ONLY _/r Application Accepted by /u� Date 'r Are / or rou�Ommede_ ion by Oate — f Final Inspection by �iGd<'/I��'^� Date�f� Additional ❑ Stk 466-6761 ❑ Lodi 369-3621 0 Manteca--$23-7104 ❑ Tracy 8355-6385 ' Applicant - Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stir.; CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY ...DATE PERMIT`NO. + EH 13.24(REV.1/a 51 cry EH 14-28