86-189 - Laserfiche WebLink

Home Browse Search

4 ` APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE..TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I . 4 (Complete in Triplicate) r 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. L Job Address _��e � .0 �!?1171T f yl.�L� City Yi[ ,7�i�ot Size PM Owner's Name Address _ �llG�� Phone 2- t Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑, DESTRUCTION ❑ - IJ11/1i-IN&TAL-L,AIBN /2f �+PA1F1�p- OT-H ER-,'9— DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL - _.-.OTHER WELL PITS/SUMPS 1 �'�-; v + -V" t, F INTENDED USE TYPE OF WELL PROBLEM AREA NCONSTRUCTIOWSPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑Manteca—_- '"'Dia—of-Well•ExcavationDia. of Well Casing VDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �c=---�-.----- ��Irc ter ❑-Delta Depth of Grout Seaa"I s Type of GToui M-.-.,---.--- ❑ Irrigation ___4pprox. Depth El Eastern Surface Seal Installed by 15 Repair Work Done ❑ Type-of Pump H.P. _ 4 State Work Done "eLZ f„.E - ZM6E5C72` Well Destruction ❑ Well Diameter Sealing Material (top 50') • �`'° t` t '. .PU�� N1JTrY .SeSy/c sz."& Depth Filler Material (Below 501 v� 1�1.:r i 1 .0 . TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR-/;ADD1t10N,ID DESTRUCTION El (No septic'sy§tem permitted if public sewer is ',J'4 �' 1 hvailabie within 200 feet.) ^� Installation will serve: Residence— Commercial--Other Number of living units: Number of bedrooms"� E Character of soil to a depth of 3 feet: F i Water tabledepthi ►. 3 SEPTIC TANK ❑ Type/Mfg 1 1= Capacity I No. Compartments h PKG. TREATMENT PLT. 17 { Method of Disposal Distance to nearest: Well Foundation Ploperty Line � ! LEACHING LINE ❑ No. & Length of lines �T T '4Tota 1 fength/size !� FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl t 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. — '• + F 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, l 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 that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- r tion laws of California." i The applicant must calI r all r inspections. Complete drawing on reverse sid . l Signed X_�7,, _ Title: Date: �Z FOR DEPAR ENT USE ONLY Application Accepted by Dater/ r� Area j Pit or Grout Inspection by Date Final inspection by Data tl f - Additional Comments: — E ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 , 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 CK RECEIVED By DATE PERMIT`NO. INFO CASH + EN 13-24 {REV.101831 �� /I7// %-t. �� A EH 1426