86-944 - Laserfiche WebLink

Home Browse Search

3� APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT F .4 I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E ,,.. (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 City Lot Size PM Owner's Name Address Phone r Contractor's Name a No•1 Phone D TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D "x 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 4 CONSTRUCTION SPECIFICATIONS h ❑ Industrial' ' ❑ Open Bottom ❑ Manteca Dia. of Wel! -Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ^Specifications ❑ Public 13Other ElDelta 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 Miferial (top 50') ~ - Depth Filler Material (Below 501 4, P TYPE OF SEPTIC WORK: -NEW INSTALLATION REPAIR/ADDITION.D DESTRUCTION Cl -(No-septic system permitted if public sewer is available within 200 feet.I, Installation will serve: Resjdence— fc,mmercia!Other 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 ` - t ti PKG. TREATMENT PLT. ❑ i , • 4 Method of Dis opt Distance to nearest: Well / ©� Foundation Property Line LEACHING LINE_ ji7 No..& Length of lines Total length/site FILTER BED ` '❑ Distance to nearest:i# Well e�� Foundation Property Line SEEPAGE PITS Depth Size. »number ` SUMPS Distance to nearest: WellFoundation. . .. Property.Line__ 02 _ DISPOSAL PONDS ❑ j '` � "' I hereby certify that I have prepared this application-and that the work will be-donean accordance with San Joaquin-county ordinances, state laws, and rules and regulations of.the San Joaquin Local-Health District. h. ( 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." Contractors 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."} " . The applicant mu t cal orIre it i spections. Complierdrawing on verse side. Signed Title: - ;�•� Date: --�y FOR DEPARTMENT USE 0f11LY 1, �s_ . � aplication Acceptedy � r "-'� Date--- Area x yS Grout Inspection by '1- Date 'Final Inspection by Date Z1_ 56. *final Comments:L .N� ak42, 4 466-UMI ❑ Lodi 369-3621 V ❑ Ma teca 823-7104 ;. '0 Tracy it- Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave., P.O. Box 20D9, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK ik RECEIVED BY DATE PERMIT`NO. ' INFO CASH