86-292 - 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 (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 R41es and Regulations of the San Joaquin 1 Local Health District. Job Address City �a .:.� Lot Size k ��f�f� PM Owner's Name �11�"=�lifi�L tid11� Address / 7?�� Phone Contractor L_Z1 "°17 e' Address 1&4a4_.'a L. LC.,�441 License No.J69�L. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ a SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _'�RGRICULTURE 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 ❑ Type of Pump 'H,P. State Work Done f Well Destruction ❑ Well Diameter . -Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence ZCommerciai available within 200 feet.) — Other Number of living units: --t Number of bedrooms__7ff: Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ElMethod of Disposal Distance to nearest: Well Foundatiw Property Line LEACHING LINE ❑ No. & Length of fir5es (-r � �/ - Total length/size V' FILTER BED (❑ Distance to nearest: Well Foundation' Property Line SEEPAGE PITS Depth _ySr� Size - �f Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 certifie's 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 foNDwing:"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 must c II for all required i ctions. Complete drawing on reverse side. Signed Title: ate: ¢ FOR DEPARTMENT USE ONLY Application Accepted by Ok7 J Of Date Area, �� Pit or Grout Inspection by `Data Final Inspectiori by Dat l J ,Aoditional Comments: k 'IU q4-- Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 App scant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 1 a FEF INFO AMOUNT DUE _ — AMOUNT REMITTED w -CASH RECEIVED BY / DATEEH PERMIT"NO. +EH 1,11-M(REV.1/8 57