86-786 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1-'. ' 1601 E. HAZEL T ON AVE., STOCKTON, CA IL Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " (Complete in Triplicate) FApplication 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 incompliance with San-Joaquin County Ordinance No.549 forsewage or No. 1862 for well/pump and the Rules and.Regulations of the San Joaquin Local Health District. dress Job AdV ,,) 7-1 ON � r��cr� A City` / "Lot Size IPM _Owner's Name Phone! a . Contractor's Name i rza"'n- 's L- se No. .. ��y� _ Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT i� DESTRUCTION ❑ PUMP INSTALLATION r _SYSTEM REPAIR ❑ ` OTHER El `:- DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES ��_ DISPOSAL FLD. PROP. LINE F FOUNDATION AGRICULTURE WELL OTHER WELL' PITSISUMPS { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial -- ,f .t3p>rf1 Bottom- ❑ Manteca Dia. of 1Ne11_Excava i _& Dia. ef_Well Casing-•. -- estic/Private ❑ Gravel Pack ❑ Trac Type of Casin � '� �o �} Y Yp g - 5pecifcations' � ❑ Public ❑ Other L❑ Delta Depth of-Grout Seal Type of Grout C� Q C1 Irrigation --Approx. Depth C1 Eastern Surface Seal Installed by- 'L Repair Work Dane ❑ Type of Pump 72- H.P. j _ State Work Done^ 4 Well Destruction ❑ Well Diameter- Sealing Material (top 50') Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is j ^available-within 20134eat.) I Installation will serve: Residence— Commercial— Other a `Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:'`` - - ,F _ *` Water table depth SEPTIC TANK ❑ Type/Mfg ' } - Capacity No. Compartments ' PKG. TREATMENT PLT ❑ � "- Method of Disposal 1 Distance to nearest: ` Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance toynearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth f *-Size Number SUMPS ❑ Distance to nearest: well 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 the San Joaquin Local Health District.. _ Hama owner or licensed agent's sigrfature cert'rfies.the following: "I that-in the-performance-of the-work-for-which-thislpermft-is-Tssu`ed, I 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." 1' The applicant must call for all uired inspections. Complete drawing.on reverse side. 5 Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area -rf / # Pit o rou Inspection by w J steal Inspection by�f � ` 2Z _ Date b Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621= , ❑ Manteca 823-7104 ❑ Tracy 835-M r' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,,Stk., CA 95201 k ! FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO r' DATE PERMIT"NO. CASH EH 13.24(REV.10/83) [Z7(o ! -�1 gfp EH 1428 _ l r US 7 *I�x i %V-71-7i