86-357 - Laserfiche WebLink

Home Browse Search

APPLICATION TOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT [Y 1601 E. HAZELTON AVE., STOCKTON, SCA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) LST 0 F R6Cay0AP 4 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,doaquin Local Health District. �F Job Address City Lot Size PM - C ,�� Address i Phone a d Owner's Name Contractor's Named o""`v ViGh '` �1r License No. 1A J i TYPE OF WELL/PUMP: NEW WELL',,- WELL REPLACEMENT DES7FlUCTIO OTHER El. INSTALLATION SYSTEM REPAIR ❑ `t r s 1 `_..-DISPOSAL FLD )11,� PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK-,f es SEWERVLINL ' - FOUNDATION CJS AGRICULTURE WELL" 0,0 OTHER WELL �D.i' PITS/SUMPS n-0 Yl� INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS i1 ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation �r Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ TracyType-of.Casing_ Specifications 1 ' 1 1 Type of Grout � T ❑ Public_ ❑ Ot��e.� ❑ Delta t":` , -Depth of Grout Seal ❑ Irrigation v�-_�Approx. Depth ❑ Eastern - Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.SILL 6;aa+w/d State Work pone Well Destruction ❑ Well Diameter Sealing Material (top 501 – Depth Filler Material-(Below 501 TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic syteithin200 permitted if public sewer is available installation will serve. Residence_ Commercial— Other- I Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments - ' PKG. TREATMENT PLT. ❑ .1 4 1 . Method of Disposal ,fi< Distance to nearest: Well Foundation Property Line .' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Li ne I SEEPAGE PITS ❑ Depth Size 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,lstate laws, and rules and regulations of the San Joaquin Local Health.District. -- --- " ! 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, l 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 ust call for all require inspections. Complete rawing on reverse side. r $ 1 Signed Title: Date: . � FORD ARTMENT USE ONLY _ � � � ,r Application Accepted by Date Area / _ Pit or G�rouu rispection by Da i 10, Final Inspection by Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. �4 INFO 'l R_ _457 + EH 13-24 MM 101831 a U 3?--- -b EH 1428