86-1341 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT .,,. SAN-JOAQUIN LOCAL HEALTH DISTRICT h t' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I`YEAR FROM'DATE ISSUED:` (Complete inTriplii;atel 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. Job Address r �� C, M"Ldt Size y r ' pNl . ty Ck Owner's Name lrn�ll ..._ - Address « ' `= ',t Phone ` `S�r 1 `� WRc�� , AddresCCJQnis i_61-71 Contractor_ s License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ 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. State Work Done ) Well Destruction ❑ Well Diameter Sealing Material {top 50') N Depth Filler Material (Below 50') r f TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is N available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: --A— Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Omctee!ZP �_ Capacity—V5(' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size a FILTER BED ❑ Distance to nearest: Well Foundation Property Line r. e SEEPAGE PITS 'Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation. Property Line DISPOSAL PONDS ❑ 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 I 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 appliccant�must call for all required inspections. Complete drawing on reverse side. Signed r��r Title: Q&L%Xs�.R c t, Date: . OR DEPARTMENT USE ONLY 1 Application Accepted by Date ` V 0 Area Q " L ) Pit or Grout Inspection by Date Final Inspection by t. Date � Additional Comments: ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,-Stk., CA 95201 "INFO AMOUNT.DUE AMOUNT REMITTED CASH RECEIVED BY DATE- PERMIT"N0. + EH 13-24 1 REV.1/e 5l - - _ 3 - EH 1425 47a, c a q I