86-864 - Laserfiche WebLink

Home Browse Search

APPLICATION.-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �1 \ `Telephone (209)V 466-6781 PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED ;t. ,. (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 fog well/pump and the Roles and Regulations of the San Joaquin Local Health District. Job Addres .,. {�,,. . .. .City '' Lot Size PM.:1 / Owner's NameNtlQuv-0._ Y Address 4), Phone Contract Address pQ� �?(� b7 .0 11 License No. 32g Phone 30--S +D� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �3•, I. I 7' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing ❑ Domestic/Private L Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public D Other ❑ Delta Depth of Grout Seal Type of Grout [ ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done M Well Destruction ❑ Well Diameter Sealing Material [top 501 0 "I r-.--� epth Filler Material (Below 501 TYPE OF SEPTIC WORK:,j NEW INSTALLATION ❑ IR/ DDITION DESTRUCTION ❑ (No septic system permitted if public sewer is yv�• available within 200 feet.l Installation-will-serve: Residence v Commercial_ Other Number of living units: Number of bedr oms i Character of soil to a depth of 3 feet: Water Mable depth SEPTIC TANK ❑ Type/Mfg l Capacity 1 ''��.' No. Compartments E PKG. TREATMENT PLT- ❑ Method of Disposal ' 1 Distance to nearest: Well Foundation = •r Property Line � LEACHING LINE LL�No. & Length-df lines � �(� -T% /� x ,,Tota! length/size Q V Z I _ FILTER BED ❑ Distance to nearest: Well !r12`�F4 nd �-- ./.0 `r Property Line I SEEPAGE PITS ❑ Depth �,5��._ Size Number SUMPS l"Distance to nearest: Well 13 a , Foundation--Z Q_�_-Property Line DISPOSAL'PONDS ❑ Ihereby 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 the San Joaquin Local Healtii District. Home owner or licensed agent's,signature certifies the following: "I cer4,th t in the performance of the work foir which this permit is issued, I shall not employ any person in such manner as to become subiect 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 California." The applicant mu -call fro,-ll r�e firedinspe�,ctions. Complete drawing on reverse Jside �) Signed i_ " �!`t- — "`�" Title: V . �, Date: F FOR DEPARTMENT USE ONLY ' A lication Accepted by Date iC_� Area r roust insp coon by D e r Final Inspection bv/ Additional omm trs ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 . li FEE ' E { INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT-NO. + EH 13-24{REV.i i x 5) 7 1 t EH 1428