86-791 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �I 1601 E. HAZE i ON AVE., STOCKTON, CA S Telephone 1209) 466-6781 SP� �� PERMIT EXPIRES1 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 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 E Local Health District. Job Address � 9 � °Wi949b "City cSWJ "Lot Size �e PM Owner's Name Z:4 Address - m - - Phone i <� Address 73 License No. Pone I. - Contractor h y TYPE.OF WELL/PUMP:---- +�. - NEW WELD"❑ --^- ti'WELL"REPL-ACEMENT El DESTRUCTION ❑ a._ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ rr OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES wDISPOSAL FLD.�,P_ROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL-1. t PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS"I ; ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing A ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I ca �L Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal "Type Sof Grout C> O Irrigation !!hApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Typeljof Pump H.P. State Work Done hh � Well Destruction El Well.Diameter Sealing Material {top 501 _ Depth Filler Material {Below 501 TYPE OF SEPTIC WORK:- NEW INSTALLATION EPA1R/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is _ ,, avail ble within 200 feet.) f m� —�- 33 Installation.will serve: Residence_ ommercial_ Other 'Number of living uritsi' u"1Q'm eP redFoomsfi- ) �`Character of soil to a depth of 3 feet: f Lei,table depth 3 SEPTIC TANK b"�Type/Mfg � .+18 .flCf apacity Nb:Compartments PKG. TREATMENT PLT. ❑ ethod of Disposal ' Distance to nearest: Well ! Foundation Pr, Line LEACHING LINE No. & Length of.linesv-? y �� ffTotal'Iength/size I FILTER BED O-Distance-to nearest: Well &1�le Foundation /U"L Property Line ICEr� SEEPAGE PITS �4 Depth (32, size d Number SUMPS ❑ D.stance to nearest: Well .1C1C)• Foundation fc9 Property Line S DISPOSAL PONDS ❑ i! l 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 Sari Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: 1-certify that in the performance of the work for which this 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 California'." F The applicant tcall for require inspections. Complete drawing on reverse side. Signed Title: date: { FOR DEPARTMENT USE ONLY ` OpKcation Accepted by " Date ea 7 Q 1 ` Date S i Pit Grout Inspecti by _ a"1e= Final Inspection by I I� Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant- Return allcapies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.Q. Box 2009, Stk., CA 95201 FEEAMOUNT DUE 1..M "AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO { CASH ;IUA� –fin srf7 -I I +EH 13-24(REV.1/6 5) �p��Vt] € + �� `K t7W •� � EH 14-26 ! L