86-234 - 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. Job Address S471 --flum v e. City S Lot Size PM Owner's Name Address vrf Phone - O R 7 Contractor ��`.?iL&�se}rJ5 Address © License 1%102 ��.Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ t DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL- * . PITS/SUMPS y INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation ._. ' -- Dia:of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications LI Public Q.Other` ` El 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_ `Well Destruction '❑\ Well Diameter' Sealing Material Itop 50'1 1 .1 Depth Filler Materia! (Below 50`]` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION■ DES'TRU C', available within 200 feet.)ION 0 INo septic system permitted if public sewer is Installation will serve: Residence-X- Commercial— Other -- Number of living units: ._ Number of bedrooms " Character of soil to a depth of 3 feet:- E ` ,r -- _ ; '""..""""."'Water,table depth SEPTIC TANK ■ Type/Mfg 1C Ca acit p Y-J--(O-OAD— No. Compartments PKG. TREATMENT PLT. ❑ ., ,, Method of Disposal Distance to nearest: + i Well -i a0 Foundation�b _ Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size TNumber ' ?' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 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. Home 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 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 t0 workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date#,7-Of 40 FOR D NT USE ONLY ` Application Accepted by Date a spection by Date d� 6 Final Inspection by Date Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMITTEDCK INFO CASH RECEIVED BY DATE PERMIT'NO.'� + EH13.24(REV.tinsY 70 EH 14-28