86-59 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ` . SAN JOAQUIN LOCAL HEALTH DISTRICT i ! 1601 E. HAZEL T ON AVE., STOCKTON, CA r 'l i. Telephone (209) 466=6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED," z�' - = v {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 andkegulations of the San Joaquin l ;Local Health District. r Job Address /77/0 /y. iC J tu" /C GT. cityl:M&I, Lot Siza i {-&494 4—PM . Owner's Name; 'Address 7 Phone Contract ` r Address 26 7 ✓?6 License NG.32- Z6 PhoneZ& 57-0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ '. f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS h f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of WelCCasing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications is ❑ Public ❑ Other ❑ Delta Depth of-Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth 0 Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pump H.P. State Work Done J Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth _ Filler Material (Below 501 G TYPE OF SEPTIC WORK: FNEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _ available within 200.faet.l Installation will serve: Residence "/Commercial_ Other Number of living units: -j— Number of beprooms _ 1 rCharacter of soil to a depth of 3 feet: { Water table depth SEPTIC TANK Type/Mfg W Capacity4206 No. Compartments PKG. TREATMENT-P-1-T..0—_- �,_ Method of Disposal Distance to nearest: Well . Foundation 60 Property Line.,:— LEACHING ine_,:`LEACHING LINE W lor,' No.'& Lengthoflines Total length/size o2' FILTER BED D Distance to nearest: Well r foundation s �Property Line SEEPAGE PITS ❑ Depth' Z DC Size_ 172 __ _.Number `J SUMPS # fB" Distance to nearest: Well Qt Foundation /�/ Property Line DISPOSAL PONDS ❑ 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 rules and regulations of therSan Joaquin Local Health District. �- Home%vner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which[his 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 Caljfornia." The applicant mu calf for all re ire nspections. Complete drawing on reverse d i Title:'Signed. — Date: 4112,41p - - FORDEP TMENTUSE ONLY 10, Cr Application Accepted-by- - Date�' b Area / 1 `Pif or Gt'ut Inspection-by— — Date/ Final Inspection by ° Date i 1 Additional Comments: ❑ Stk 4664781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk, CA 95201 FEE P INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. Y, + (P EV,1i857 EH 14-26