86-552 - Laserfiche WebLink

Home Browse Search

' J APPLICATION FOR PERMIT } SAN JOAOUiN LOCAL�HFALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (204) 466-6781 DATE ISSUED 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 �] Subdivision Name �� QeA ( f—I&o- y is Owner's NameC,6) Address �]�[ �(l _ �r,�y [Q Phone �_��- a�{� Contractor's Name License No. Q q $3 Phone (g g 7 7 Q TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK J��"r"""(-'4-SEWER,LINES_ DISPOSAL FLD.. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER,WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial Open Bottom ❑Manteca Dia. of Well Excavation { ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public I ❑a ❑ OthIer ❑ Delta ; /M Type of Casing T Yirrigation Approx. ❑ Eastern I Depth Specifications ❑Cathodic Protection Depth of Grout Seal 1-1 Geophysical Type of Grout F ❑Other Surface Seal Installed by ")f y pjZl� Ire Repair Work Done Type of Pump S%) H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') } T SEPTIC WORK: NEW INSTALLATION ❑ REPRTR/ADDITION —J (No septic tank or seepage pit permitted if public sewer is 1 ' available within 200 feet.) 1 Installation serve: Residence — Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of'-3 x Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments f PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well o tion Property,Line DESTRUCTION. LEACHING LINE U No. & Length of lines Total a size FILTER BED ❑ Distance to nearest: Well Foundation Prop Line SEEPAGE PITS ❑ Depth Size Number SUMPS L 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 1 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I 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, I shall not employ any person in such manner as to become subject to workman, compensation laws of California." Contractor's 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 compensation laws of Cal ifornia. The applicant mW call for all required inspections. Complete drawing on reverse side. Signed X a,/A..�f\I 11 A/1tA&'1',_ Title: Ce— S Date: a A TM SE ONLY Application Accepted b- Area O S ❑ Stk 466-fi781 Additional Comments:ed� ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection, Date y. /U'�'t{`�•, L7 Tracy 835-6385 Applicant - Return all copies to: . Envir ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECETVEQ BY DATE 'PERMIT NO. INFO If 3Steo 5 3a _8p 1Pta`s�z EH 13-24 REV. 10/82 10/82 500 14-26