86-1532 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.; STOCKTON, CA Telephone (209) 466-6781„ F. t PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to;;; he 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 Regulations of the San Joaquin Local Health District. Job Address �1`7!n�� N; LL t�1+C• City Lot Size � d PM Owner's Name i Address 26537 C&& �'�e.0-Q I Phone qj S �- o �p Contract 06 Address 06 77_ 7j6I��LG�. License Noc d1�2-Z _Phone `S�� TYPE OF WELL/PUMP: iM NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑'"Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i P ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i ❑ Public ❑.Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation_.__. - �_ pprox. Depth �❑ Eastern _ Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. � State Work Done Well Destruction ❑ Well Diameter 5ealing f+Aate"ria) stop 50'1 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 11 available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units:----F-!-- Number of bedrooms f Character of soil to a depth)of 3 feet: Water table depth «90 SEPTIC TANK 9K,!Type/Mfg 1 + Capacitya,90 No. Compartments PKG. TREATMENT PLT. ❑ [ ; Method of Disposal Distance tot,nearest: Well Foundation Property Line LEACHING LINE �I`No. & Length#of lines *. .. Total length/size X FILTER BED ❑ ('Distance to nedr_est: Well•L r foundation e O r Property Line 15— f SEEPAGE PITSDepth `-<" Size L� Number -SUMPS ❑ Distance to nearest: a Well-lSr* Foundation 7L/—Q 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health_District. *1 ame owner or licensed agent's signature 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,manne�as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I ce if y 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 must call for all rSquired inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by ` Date Final Inspection by Date l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6.385 Applicant- Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I� + EH 1 -241REV.t/e5> � '' CSO �Y'� EH 1 4-28 ,� �'tSly 453