91-1431 - Laserfiche WebLink

Home Browse Search

E APPLICATION FOR PERMIT �? SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE,-"QNtAVE., STOCKTON, CA ` Telephone (209)466-6781 ..A PERMIT EXPIRES '#YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thison 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 theapplicati San Joaquin Local Health District, Job Address City rite PM Ip a n Owner's Name / Address J_R,ALy Phone Contractor ` �� Z �� Address License No.1 _Phone TYPE OF WELL/PUMP: NEW WELL ❑—` WELL REPLACEMENT ❑ DESTRUCTION ElPUMP INSTALLATION !d SYSTEM REPAIR 2— OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLf PITS/SUMPS Tr� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ndustrial ❑ Open Bottom ❑-Manteca Dia. of Well Excavation Dia, of Well Casing t ,, Domestic/Ptivate - R ❑ Gravel P,ack� ❑ Tracy r Type of Casing Specifications M Public 17l Other, ❑ pelta Depth of Grout Seal - . xR �.. — - .�--�,,._ Mepth of G ..r-.,__ Type of_Grout ! I Irrigation _..Approx. Depth�I I Eastern S rf Ice Seal Installed by Repair Work Done Type of Pump ' , H.P. State-Wolk.�Done Well Destruction ❑ Well Diameter'_ � Sealing Material.ftop.50') ' ` T Depth. ? �.l .y�, '- Filler Material (Below 50') _`� " - .1 14 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/AUDITION I I DESTRUCTION I I (No septic system permitted if public sewer isr'r, available within 200 feet.) }` Installation will serve: Residence_ Commercial_ OtherI t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ,i SEPTIC TANK ❑ Type/Mf W#er table depth ;+ a Type/Mfg apacity No. Compartmentsspl; i PKG. TREATMENT PLT. ❑ # f i�� Method of Disposal Distance to nearest: Well Foundation Property Line r i r i LEACHING LINE ' ❑ No. & Length of lines t.- Total length/size FILTER BED ❑ Distance to nearest: I Founda n Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Weil Foundation _ DISPOSAL PONDS ❑ Property Line F 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 regulatio San Joaquin Local Health District. Home owner icensed ag is signature certifies the following: "I certify that in the performance of the work forFwhich this permit is issued, i shall not employ an arson in such nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies a following: "i fy that in the per(or ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- ; tion la of Califo nia." Thea plicant m all or all i �. plate drawing o e �sWi / Signed , Title: Date: . FOX!:r6ART E ONLY i Application Accepted by Date 2-� ! ► Area Pit or Grout Inspection by Date Final Inspection b 3 �— Date h Additional Comments_: 1 ❑ Stk 46di 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 6-6781 ❑ Loi� 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 CK INFO CASH RECEIVED BY DATE PERMIT'NO. 1 �. ti + EH 13-24(REV.1?H 51EH 14-28 1-14 r' ,f. t