86-147 - Laserfiche WebLink

Home Browse Search

r= \ APP�YCATION FOR PERMIT J�1 �i. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 incompliance 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. t 11, Job Address . � e ti hd/,1. 4 City `Lot Size. PM Owner's Name 1bSJ46k1,!Widdress 1 Q Phone r:3 I f 3 Contractor's Name P icense No. Phone TYPE OF WELL/PUMP: IL k NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -' r' PUMP INSTAL-L�,4TlONS SYSTEM REPAIR ❑ OTHER ❑ 'i r DISTANCE TO NEARESDTIC TANK �_. SEWER LINES DISPOSAL FLD. PROP. LINE t 'k� UNDATION `_ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USEr4L� TYPE OF WELL'S PROBLEM AREA CCONSTRUCTION SPECIFICATIONS �- ❑ Industrial, fF06pen Bottom ❑ Manteca D4.,of Well Excavation Dia:of Well Casing fL ❑ Domestic/Prhiate ❑ Gtavel Pack r,. ❑ Tracy ` Type of Casing Specifications Cl Public ❑ Other '�' ❑ Delta �i Depth of Grout Seal Type of Grout ❑ Irrigation f' Approx. Depth ❑ Eastern"_ ,.5u l y—Seal Installed by Repair Work Done ❑ Type of Pump 41., H.P. ' State Work Done Well Destructionj ❑ WeII�Diameter Sealing,Materialltop 501 `l *Depth « Filler: a.erial {Below 50'1 i J vfy _ TYPE OF SEPTIC WORK= NEW INSTALLATION ElREPAIR/ADDITION ElDESTRUCTION LJ (No septic,system permitted if public sewer is ftp r3 t� ., . -- f available within 200 feet.) Installation will serve:''•Residence_ Commercial_ Oth�Me Number of living unitsf� �-, Number of bedrooms I Character of soil to a dep' th`tSf'3 feeit �%"r -'` Water table depth SEPTIC TANK 11 �T}ype/Mfg Capacli.. —No:"Cornpartments PKG. TREATMENT PLT. .r Method of Disposal Distance to nearest: Well Foundation"'-^'""—'' 'Pffperty-Line LEACHING LINE 91_'iVo. & Length of lines Total length/s ( FILTER BED �: Distance to nearest: Well Foundation Property Line y,i, Number flNL i. SEEPAGE PITS Depth _.. _5ize �; SUMPS,_ ❑ .,hDh��istanceto nearest: Well Foundation Property Line j�DISPOSXUPONDS, ❑ 1�P I hereby!certifyr;that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and,regulatioris:of,,the Joaquin Local Health District. Y Home owneitor licensed.a a s ignature 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 lr��per as to become subject to workman's compensation laws of California."Contractoes hiring or sub-contracting signature certifies the following:"I certi 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." p The appli t call for all ll` ired in pections. Complete drawing on reverse-side. �N Title: s Date: —/ Signed + FOR DEPARTMENT USE ONLY - 1 __ Application Accepted by Al. Area i �� Dated Pit or Grout Inspection by " Date Final Inspection by� Date Additional Comments: IQ 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 licant- Return all copies' Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED C K IN RECEIVED BY DATE PERMIT-NO. INFO IL + EH 13-24IREV.10/83) O �� A 1 EH 14-26 - -