86-811 - Laserfiche WebLink

Home Browse Search

�. APPLICATIQIII FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON,AVE., STOCKTON, CA z 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 Regulatio of the San Joaquin ' Local Health District. — / t t�e,� 7 2 Job Address '� � r + City �"�r a Lot Size.3 719CPM I Owner's Name F l © r-upi c Q, I — Addr ass W 22 O�`-' '' A4k 26 .— Phone u7 ,? 1/ i l Contractor C64 PICC WGIL Address 2 6:7 6714 License No. 3 7tJ Phone " TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATIO �; SYSTEM RE Ar OTHER OTHER ❑ C on DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES �I—I DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC IW ❑ Inddu rial El Open Bottom El Manteca Dia. of Well Excav�i n Dia. of Well Casing 8 Domestic/Private mel Pack ❑ Tracy Type of Casing Specifications •'� ❑Public CI Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern urface Seal Installed by n Repair Work Done ❑ TT pe of Pump M.P. to Work one lJVr� L - Well Destruction - C� Well Diameter `�--��-- Seating Material {top 5d'1 6 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) 'Installatlo . serve: Residence Commercial____ Other !Number of living un Number of bedrooms Character of soil to a depth o t: l Water table depth SEPTIC TANK ❑ Type/.Mfg <. CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines otal length/size FILTER BED ❑ Distance to nearest: Well Foundation arty Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 y 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."Contractors hiring or sub-contracting signature certifies the following:',I certify;Wt in the performance of the work for which this permit is issued,i shall employ persons subject to workman's co nsa tion laws of California." The applicant s call I d i cti s Complete drawing on p =side.'° _ " Signed .'Title: — //7_ �� Date: � `,,/ FOR D ARTMENT USE ONLY / Application Accepted by y Data f — � rea k 02 3' ate , Pit o Grau Inspection by Date Final Inspection by Additional Comments: ❑ Stk, 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823,d104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. { INFO + EH1324(REV.7/95) EH 114.25 AV } tl