86-967 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZELTON 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 rr. .made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. x C� (�Q� PM Job Address I C-,� � `�'`'"� �� City "Cot Size ` Owner's Name Address Phone q _— Contractor ,�4rZ S t C Addressd 600 M "- ke , _ License fNo. S� Phone .. .TYP.E.OF_WELL4PUMP:-�. NEW WELL—Q— WELL REPLACEMENT-E]— DESTRUCTION-❑- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES YDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL *! OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS"— `—: El Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation ` Dia. of Well Casing LJ Dom estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i of Grout 4 11 Public •IJ Other ❑ Delta Depth of Grout Seal S rt----- __--._ .____T,.�._ . ❑ Irrigation --Approx. Depth ❑ Eastern Surface'4Sgal lnstalled'by" t T i H.P. - . State Work Done Repair Work Done ❑ Type of Pump Ate.Well Destruction ❑ Well Diameter Sealing Material (top 501" y+ Depth = ,r�t �F Filler Material IBetow 50') # "k i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Cr DESTRUCTION ❑ Wo septic system permitted if public sewer is M available within 200 feet.) . v. Installation will serve: Residence... Commercial—73, Other Number of living units: Number of bedro 4 Character of soil to a depth of 3 feet: s4vibWater table depth - SEPTIC TANK E3Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ( *" Method of Disposal _ Distance to nearest: Well Foundation Property Line 'r LEACHING LINE IJ( No. & Length ofilines — N`" s sin Total length/size , FILTER BED ❑ Distance to nearest: Well &W Foundation��! Property Line C SEEPAGE PITS ❑ Depth Size tNumber s m SUMPS 'k' Distance to nearest: - Well Foundation Property LineC�-.- R� DISPOSAL PONDS ❑ I 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 r ulations of the-San Joaquin Local Health District r ` Home ow r licensed agent's 'gnature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ an per on in such ner as to become subiectfto workman's compensation laws of California." Contractor's hiring or sub-contracting signature ' certifies th follo ing: " rtify that in the performanc6�of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws f C i mi The applic t call for all required inspections. Complete drawing on reverse side. Signed �' Title: e�l�`R�. Date: 8-� OR DEPARTMENT USE ONLY Application Accepted b Date Area Flo Pit or Grout Inspection by Date Final Inspection by Date ®CO Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to- Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 13-241REV.1/651 'Do EH 14-28