86-717 - Laserfiche WebLink

Home Browse Search

APPLICATION-FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 _ PERMIT EXPIRES 1.YEAR FROM DATE ISSUED Y". Y .,(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 Re ula'on of the San Joaquin Local Health Distrirt' 73 - i lar i 5.SO V zp"l „C � '� 1�'p y �§PnLot Size � PIC� PM� [Jd^� Job Addrcessess _ City sL - Da_ 1 n Phone (� OwnerM ' _ Owners Name f '.� S Address ContractorI—rTAd License N%. '�._..l phone TYPE OF WELL/PUMP: NEW_WELLF WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO-NEAREST: SEPTIC TANK'�T•a. SEWER LINES DISPOSAL FLD. PROP. Lt INE ' { FOUNDATION_' r AGRICULTURE WELL OTHER WELL-----!- PITS/SUMPS +. INTENDED USE TYPE OF WELL PROBLEM AREAJ0,C9NSTRIJCTI0N SPECIFICATIONS, r ❑ Industrial El Bottom f ❑ Manteca ` Dia. of Well Excavation IDia. of`?ell Casing t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ; ❑ Irrigation --- x-ApproDepth,j ❑ Eastern Surface Seal Installed by Repair Work Done EJ Type of Pump H.R.-.- -State Work Done= f� Well Destruction""'"p"" Well p Diameter Sealing Material (top 501 . 01140-1##/ rvnl Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is " " available within 200 feet.► ,Installation will sive: ResidenceC�m�e�rcah_ Other ' s Numberf living units Number of bedrao s f .....�. .� Character of sail to a depth of 3 feet: ,5-, r table depth SEPTIC TANK ❑ Type/Mfg Cr icapacity "7 V2 No. Compartments PKC- TREATMENT PLT. El '*)0 k 4�� Method of Disposal Distance to nearest: Well D Foundation_IP ! Property Line r LEACHINGLINE ❑ No.&;Length of lines # }+0��T taf�length/size I FILTER BED ❑""Distance to nearest: Well Foundation S7Property Line�3CJ- T 10e ,•. SEEPAGE PITS ❑ Depth Size , -.. Number y -x L� ` , I. SUMPS .. El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ >. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinancas, state laws, and rules and regulations of,the San Joaquin Local Health District. y Home owner or licensed agent's signature certifies the following: "0certify that in the,performance of the work for which this permit is slued; I shall not r 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: "/certify that in the performance of the work for which this permit is issuued, I shall employ persons subject,to workman's compensa- tion laws of C lifornia.'r' .; The applica �rlust call for aI it kinspection . Complete drawing on reverse side. ; Signed X Title:♦ 4L❑1 �"` Date: � S�y EPARTMENT USE ONLY ° � 1 _AppUrtion Accepted by Date 3C7- + Area �Pitr Gr t Inspection byA Final Inspection b Date Additional Comments: ❑ Stk 466-6781 11 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 INFO AMOUNT DUE, AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMITNO. ,syr + EH 13-24 MEV:1/H-5f � �! �o^ ! (7 • EH 14-26