86-1314 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F. 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 A/�O �� City Lot Size PM Owner's Name �liG2T lezlOL- 5�� Z Address Phone .'�—/ Contractor �t7�O 057 Address �"� >�UX�� ff lam' License No, z�prf/ Phone 6S=Zd/ j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f 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 q ❑ Domestic/Private EJ Gravel Pack C1 Tracy Type of Casing c� ❑ Public . Specifications I ❑ Other El Delta _ _ "Depth o-f Grout Seal"`' '—— ❑ irrigation �Ype of Grout i ---Approx. Depth ❑ Eastern Surface Seal Installed by i i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter ! Sealing Material (top 4) Depth Filler Material (Below 50') T I I� f YPE OF SEPTIC WORK: NEW INSTALLATION IF REPAIR/ADDITION f DESTRUCTION ❑ (No septic system permitted if public sewer is 1 4--- --�� available-within-2W-feet') Installation will serve: Residence Commercial Other `1 Number of living units: Number of liedro�ms Character of soil to a depth of 3 feet: i I k SEPTIC TANK ❑ Type/Mf -Water-`tabl�epth Type/Mfg Capacity No. Compartments, PKG. TREATMENT PLT. ❑ / MethoJI of;Disposal Distance to near t: t; Wel! Fo'ndation. - Property Linal LEACHING LINE ❑ No. & Length of lines — Tota! length'/size Zr FILTER BED g/ Distance to nearest: Well ��— Fo[ndation __� Property Line ti SEEPAGE PITS ❑ Depth Size Number ..� SUMPS ❑ Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ f 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. I 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, 1 shall not f - - .employ any-person in such manner.as to become subject to_workman's.compensation laws.of California."_Contractor's..hiring or sub-contracting signature I certifies the foflowing:"I certify that in the performance of the work for which this permit is issued,I shall employ tion laws of California." P Y persons subject to workman's compensa- The applicant must I required in ons. Complete drawing on reverse side. 4 Signed t. Titib: Date: FO EPARTMENT USE ONLY Application Accepted by - Date �^ qn3� I x Pit or Grout Inspection by Date Final Inspection by Ap��a"3 / Da e Additional Comments: 1el011 ❑ 5tk 466 6781 ❑ 1116di 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 / 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK INFO qq CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.F/a 57 O. V 0 EH,428