86-1149 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a (Complete in Triplicate) i 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. j p Job Address ...../ / 1C >`U�� _ _L��_ .___ _ City ST/�" Lot Size PM Owner's Name 4-0- 14f 1119,e 49 ,�k/E_Mddress Y�-� Phone y Contractor's Name /'/�iP/�/q/V`5`; fT . License No. 7`� %� '; Phone TYPE OF WELL/PUMP: NEW WELL p I�,' I_ WELD RIEPLACEMENT" DESTRUCTION ❑ PUMP INSTALLATION 3 —�T SYSTEM REPAIR ❑ OTHER ❑ r DISTANC�O-NEAAEST:,SEP_TIC TANK E1lILER�iNES..=__ DISPOSAL FL@_ 1j PROP—LIIa[E z/ _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF{CATIONS ❑ Industrial ❑ Open Bottom ❑ Ma4dca� Dia. oPWelutccaVa'�ion, !� Dia, of Well Casing 1.1 Domestic/Private Q7Gravel Pack ❑ Tracy `�'p� t Type of_Casing_ PYG.. .- Specifications ❑ Public ❑ Otrer _ ❑�De�a eth of Grot Seal xJl z' Type of Grout - I ❑ Irrigation q(� pprox. Depth ❑'Eat in 'Sukace Seal1nnstalled by i Repair Work Don ❑ Type of Pump H. ��1 State Work Done Well Destruction ❑ Well Diameter s Sea ing`Aate, I-(#op_50 Depth ��Filler.fUlatenal (Belo�lnr'50�) t'; TYPE OF SEPTIC ORK: NEW INSTALLATION ❑ REPAIR%A-DDTTION-❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will ewe: Residence____ Commercial r` Other Number of livinj units: Number of bedroori S. Character of soillto a depth of 3 feet: ' Water table depth F SEPTIC TANK ; ❑ Type/Mfg r'Capacity No. Compartments PKG. TREATMENT PLT, ❑ l s Method of Disposal Distance to nearest: Well _ Fog dation Property Line x LEACHING,LINE ❑ No. & Length"of Aines _ Total iength/size FILTER i p-D El Distance to nearest: Well t �` Foundation Property Line SEEPAGEIPITS ❑ Depth Number SUMPST- "❑ Distance to nea st: `WeII Foundation Property Line r DISPOSAL POND ❑ I hereby certify th t I have prepared this application and that thework will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulatiohs of the San Joaquin Local'Health District. _ Home owner or licensed agent's signature certifies the following:l"I certify that in the performance a of,the work for which this permit is issued, I shall not employ any person in such manner as to become subiect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followi g:"1 certify that in the performance of theme work for whi6h this permit is issued,I shall employ persons subject to workman's compensa- I tion laws of Califo ria." 1 I ! l 1 The applicant mu call requir d ins cti to drawing on reverse side. l rCJ l .S red Title:} � Date: 4IETMENT, SE'QNLyFU f Application Accept d by Date ` r Area �: f Pit or rout nape ion by Dae Final Inspection by Date So `Additional Comme ta. ❑ Stk 466-6781 ❑ Lodi 369-3$21 ❑ Manteca 823-7104 ❑ Tracy 835-6385 w Applicant- Return II copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f INFEl AMOUNT DUE - AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. Hwy t 13-24(REV.10183) \ eH 1428 114 4 rm .