86-433 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �2 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. /_ Job Address / `�/ f�`T�/ �4.t� /Cf� City 4d.4 Lot Size' PM f Owner's Name if/Al �l/�c1 Address �8^) phone Contractor !q!5/ '14 ddress .P77C.reT$"J License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Pl1A01R•INSTALLATION {]'-- SYST-EMF-flEPAIR ❑ , ___ _-OTHER ❑ .- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS: r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of W*r&sing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta " Depth of Grout Seal " Type of Grout ❑ Irrigation _Approxi Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Materia((Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is W �/' available within 200 feet L _ Installation will serve: Residence d_ Commercial_ Other LN Number of living units: -/— Number ofyyb,.edd�rooms Character of soil to a depth of 3 feet: L��l.44 S/ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property:Line ,+y.e..w...a. � 0 LEACHING LINE �—No. & Length of lines "�' 0 �" ,��Total length/size FILTER BED ❑ Distance to nearest: Well � Eoundaion Property Line SEEPAGE PITS L'T Depth o25-/CT Size " NVM'ber 3 SUMPS n Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ I hereby certify that 1 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. 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 for all uired inspections. Complete drawing on reverse side. Signed Title Date: F DEPARTMENT USE ONLY Application Accepted by Date Area Grout Inspection by ate Final InspPtion by G ' Date �J Additional Comments: 009, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8135-6385 Applicant- Return all opies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED yC K 4 (RECEIVED BY DATE PERMIT'NO. + EEH 13-24 H 1428(REV.t/8.5) /I ✓ 0