86-1098 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 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. Q ��, (� /� /, Job Address b/ U � 4 e 4'n e City J Lot Size Zy[�V��+'l PM Owner's Name U24d 2l/dv _ Ad+ress J p -, Pbone d '—Y/— O1 \ M11J Contractor r l Address / � P License No. � �Phone YY TYPE OF WELL7PUMPi"'" NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR.Ot OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL %PROBLEM AREA CON STRUCTION.SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing i 4 -Specifications ❑ Public ❑ Other ❑ Delt�a� Depth of Grout Seal t Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern ,## Surface Seal Installed by N Repair Work Done LJ Type of Pump H.P.1 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION If REPAIR/ADDITION ❑ DESTRUCTION ❑'INo'septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence v Commercial_ Other ¢ • !Number of living units: Number of bedrooms ti Character of soil to a depth of 3 feet- Water table depth SEPTIC TANK El ` Type/Mfg * Capacity' �� I No. Compartments r a PKG. TREATMENT PLT. ❑ � � - Method of Dispose 'f}n49 Distance to nearest: Well Founr dation��;Property Line �.--� LEACHING LINE No. & Length of lines _ T al length/size FILTER BED ❑ Distance to nearest: Well /-00 Foundation i Property Line , 9i�Vt 04 g�N + • 0SEEPAGE PITS ❑ Depth Size jumber 2 SUMPS ❑ Distance to nearest: Well J(D41yFoundation 100'4 Property Line /,T0 DISPOSAL PONDS ❑ r.' 1,I � d I hereby certify that I have prepared this application and that the work will be,dine in accordance with San Joaquin county ordinances, state laws, and rules and reguiati�Vhe San Joaquin Lecal,Health District. Home owner or 0 6'%gent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in snch' `nner as to become subject to workman's compensation,laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify}het<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 applica must call for I required inspections. Complete drawing on reverse side. Signed X Title: _ —_ Date: l 3y{D 1%N ! FAM DEPARTMENT USE ONLY Q Application Accepted by c� r_ .i Date y—�` Area 0 y Pit or Grout Inspection by Date 9` Final Inspection by QKAA Date Additional Comments: + e-- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca4p'M-7104 wt'❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health PermrtlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO" + EH 13-24[REV.t/R s) EH 14-28 //