86-1164 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMITo4z� 9772qj SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 � J�O V �C I� City Size PMJ� Owner's Name `J e 17 L.1 ► IZddress T 2 S0 i Valva, P6one — Contractor �Ptu l I+ Address—PO x 1 7 -2 42373 b" 6 -. License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DI POSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done *r'�Type of Pump (4,6 — ._ H.P. I A/ `` • -- d State Work Done - Well Destruction ❑ Well Diameter . ' Sealing Material {top 501 Depth 1� J, Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms w Character of soil to a depth of 3 feet: P Water table depth SEPTIC TANK, ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT,PLT, ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE: ❑ 'No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well FoundationProperty Line J / SEEPAGE PITS ❑T Depth' Size Number 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.r Home owner d agent's signaturecert les the following: ''I certify that in the performance of the work for which this permit is issued, I shall not employ an rson ins ch manner as to b subject to workman's compensation laws of California.- Contractors hiring or sub-contracting signature certifies a following: 'I ertify tha n e rf rmance he work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laf w oCaliforni .' The a licant c for a re ions. C mplete drawing onr me slid CtSigne �' Title:IF �/11R�10. Date: f ` FOR DEPARTMENT USE ONLY Application Accepted bye Date 2- Area Pit or.Grout Inspection by" Date Final Inspection by date 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354335 Applicant-'Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH13•Y4iREV.tia5) S f�s EH 14'zJ /