86-320 - Laserfiche WebLink

Home Browse Search

fit r f APPLICATION FOR PERMITt^ Hlryhe5 Cor1st, SAN JOAQUIN LOCAL HEALTH DISTRICT State Lic. 4P207177 1601 E. HAZELTON AVE.,,STOCKTON, CA 263 S. Cro f,,v4a Telephone {209? 466-6781 Stockton, CA 90,20 a 3937 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Phone: (209) - (Complete in Triplicate) . /ZA10f11,C2 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. if>/ ,: . .O ZLo--r- C) i�. Lot Size .. 2 '1SIUi GTS__ crty.- ; Job Address �_ ` ..:sr.. s' �" .-SII. r . Owner's Name 4V2Ji7 -Address"„' hone f ^ i Contractor's Named '` License No. Phone TYPE OF WELL/PUMP: %NEW WELL d 1 WELL REPLACEMENT. ❑ EDESTRUCTION © (�5 —�?� 71 1 'Y PUMP,,INSTALLATION ❑� u'-$STEM REPAIR r�❑ BOTHER 0 DISTANCE-TO NEAREST: SEPTIC-sANK\ 3 SEWER LINES .f t�DISPOSAL FLD!�i PROP. LINE FOUNDATIOI4, t• ',AGRICULTURE WELL N OTHER WELL' PITS/SUMPS INTENDED USE TYPE OF WELL . �PROBt1If AREA CONSTRUCTION SPECIFICATIONS ,..❑ industrial C100en Bottom , Manta "'' cDia.761Well Excavation ' Dia. of Well Casing Domestic/Private 11 Gravel Pack: Tracy Typ of Casing- 0 J^ Specifications r 7 r�� `t%f t. Type of Grout ❑ Public ❑ Other - ❑ Delta Depth of Grout Seal" ;r ❑ irrigation ---Approx. Depth D Eastern Surface Seal'installed by ,- r Repair Work Done ❑ Type of Pump — H-P..' State Work Done Well Destruction 1:1 Well Diameter ?'� A*`Zing Material (top 501 j Depth I5 F.illes Material,( 501 VI _ t TYPE OF SEPTIC WORK: NEW INSTALLATION :!REPAIR/ADDITION O DESTRUCTION EI (No septic system permitted ifypublic sewer is - \ � available within 200 feet.) Installation will serve: Residence zJ Commercial_ Other Number of living units:__/_ ilk of bedroom r; Character of soil to a depth of 3 feet: : Water table depth SEPTIC TANK Type/Mfg e' .lrapacityo. Compartments PKC. TREATMENT PLT. F7I Method of Disposal Distance to nearest: Well ®! F6untdation Property Line r - length/size fen LEACHING LINE � No. & Length of lines "� !� y. �Total g FILTER BED El Distance to nearest: Well��/ Foundatii I Property Line j SEEPAGE PITS I)II Depth Size %." Number SUMPS ❑ Distance to nearest: Well a<`�� Foundation f — Property Line_ II DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance withySan Joaquin 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 mu required inspection C a drawing on revs , Signed 0 Title: Date: R FOR DEPART T USE ONLY - r ` £ Area Application Accepted by Date Pit or Grout Inspection by Date �c Final Inspection by Date Additional Comments. . R Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy B35 6385 i App nt- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1pF0° AMOUAET_pUE,. �L --AMOUNT REMITTED. - - C .�. RECEIVED-BY--� rir- oATE-� -.L-i-IFERMIT N0.— 'o :- i E a-24 IREV.loreoi EH 14-26 - '