86-1453 - Laserfiche WebLink

Home Browse Search

i ,yam APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZE 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. 1 Jab Address / City_4 l 4142CWLot Size PM R Owner's Name f �i% Address . ,1 r 1a,-M) Phone Contractor_ 'fDlJ,P/l�.q�1 ..5 5. Address L G icense No. Phone �7 Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION J SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE -r. .TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I 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. Z, State Work Done ,Ge7/ Well Destruction ❑ Well Diameter Sealing Material (top 501 -1ZVB dV-*l IVr L[J Z�d�_�i�1e�t ? Depth Filler Material (Below 501 6 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 bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑r ' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size y FILTER BED (I ID Distance to nearest: Well Foundation Property Line f SEEPAGE PITS ❑ Depth ``4Slze ' �`s�1 Number f SUMPS LI Distance to nearest: Well -IS)""44(1Faundation Property Line r DISPOSAL PONDS r-1 s 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. a, Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for hich-this permit is issued, 1 shall not employ any person in such manner as to become subject-to workman's compensation laws of California."Contractor's hiring or sub-contractr ig signature ' certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ parsons 4ubject to workmanCs compensa- tion laws of California." i y mf <, s. I The applicant If r all ui inspections. Coplete drawing on reverse Signed [ fTite: t Oate:. i FOR DEjPARTMENT USE ONLY Application Accepted53 + Date Area rDZ'; . Pit or Grout Inspecti y Date `� Final Inspection by —"� Date -4 K. Additional Comments: _ ❑-Stk-466-8781--'—❑-Lodi-3W3611 - '❑'Mahteca'"823 104:-' L7-Tracy 835=6385 "�'- `` '• Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201FEE s INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. + E4(REV.1/85) �J. O� EN 14-28