86-992 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.;;STOCKTON, CA "Telephone (209) 466-6781 PERMIT EXPIRES1 YEAR FROM DATE LIED h i .iComplete 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 f 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. *, 9 f e ,r Job Address +/ �� City��p/ iV�CG�ot Size �� — PM Owner's Name Address Phone Contractor ;Address 'd ! �/G License No. '1�X6 Phone 67 TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE;t "NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL_FLD. PROP. LINE 7` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED:USE r TYPE OF WELL 'PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open,Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private D Gravel•Pack ❑ Tracy Type of Casing Specifications ❑*ubfic— -�-- "I];=Other h --Q'flelta """ """(3epth of'Gr`out Seal` " -"Type 60 gout r ❑LIrrigation --Approx; Depth ❑.Eastern Surface-Seal Installed by Repair Work.Done ❑ Type of Pump `+ H.P. rj" State Work Done k Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No'septic system permitted if public sewer is - f available within 200 feet.) Installation will serve: Residence Commercial_ Other �` "" `� J Number of living units: _f' Number of bedrooms �; r l Character of soil to a depth of 3 feet: S,f�1J DV ` Water table depth f a SEPTIC TANK ,`,❑'• Type/Mfg Capacity No. Compartments I ; PKG. TREATMENT PLY. i] t r Method of Disposal i i ,.!� - r"Distanc\e.to nearest: Well Foundation Property Line by LEACHING LINE No. & Length of)ins �~ /� Total len th/size FILTER 8ED .Distance to nearest: Well Tn Foundation ��P' Property Line �T SEEPAGE PITS D Depth Site x�. Number :' � SUMPS ElDistance'to nearest:-• Well, #Foundation-- w - _ P,,perty.,Line t DISPOSAL PONDS ❑ hereby certify that I have prepaied 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 compensatioh-laws_of,California."Contractor's hiring or sub contracting signature certifies the following: 'Ef 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 must call for 1 requir clinspections. Complete drawingfoII reverse side. e Signed X Title Date: ( G F DEPARTMENT USE ONLY l I/ Application Acce ted ti - - Date- Area Pit or Grout Inspection;by Date Final Inspection by Date ( Additional Comments: ❑ Stk 466-6781 ❑ Lodi•`369-3621 :,. ❑ Manteca 823-7104 .❑ Tracy 835.6385 ' i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.,Box 2009, Stk., CA 95201 t j FEE AMOUN2 DUE' AMOUNT REMITTED CK. RECEIVED BY DATE PERMIT'NO. s _INFO, ._--- - _ . .._. _....._.... .. .. CASH r Q x .-.. +-EH 13-24(HEV.5/H 51 r / C3._...` �..•—,-�--. .._.,,,,,�_ ...-,.. -' — - EH 14-2a