86-259 - 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) Applicaon is all the work cation is made inti compliance werebyrith SanoJoaquthe in County Ordinance Nn Joaquin Local to.District549 for sewage or permit 1862 forcwell/pump atand the Rules-and herein gu ations of he Sant Joaquin Local Health District. Job Address O �' Clty�; ` Lot Size c�-�vr�/ r PM SoIV Address 2n,- ` ZQQCS_�-" Phone 6721 Owner's Name a� Q - � Contractor's Name License No. '!43� 48 S Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION CJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta L Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern t."Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done '} Well Destruction ❑ Well Diameter Sealing Material (top 50') V� Depth Filler Material (Below 501 I n TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is N available within 200 feet.) Installation will serve: Residence Commercial Other mm !Number of living units: Numberof STof bedrooms 0 1 Character of soil to a depth of 3 feet: C " Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation--Property Line t LEACHING LINE 15 No. & Length of lines X LIC Total length/size- FILTER ength/size FILTER BED ❑ Distance to nearest: Well 'Foundation'L— Property Line SEEPAGE PITS ❑ Depth Siie ' Number SUMPS ❑ ,Distance to nearest: Well i Foundation Property Line , DISPOSAL PONDS ❑ UI 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 certifies the following-. '.'I certify that in the performance of the work for which this permit is issued, l shall not employ Imst such manner as to become subject to workman's compensation laws of California."Contractoes hiring or sub-contracting signature certifies he :"I certify that in the performance e'work for which this permit is issued,I shall employ persons subject to workman's compensa tion la of ." . The app'caall far requi spections. Complete drawing on reverse side. ( ` Title: Date: — Signed FOR DE RTMENT USE ONLY Application Accepted by "� Date Area �s Date ^� T Pit or Grout Inspection byData Final Inspection by,� yyta Additional Comments: "v �u C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ &Aanteca 823-7104 Tracy 835-8385 Applicant Return all copies to: Environmental Health Permit/Se'rvices 1601 . Ha elton Ave., P.O. Box 2009, Stk., CA 95201 ei 4'91� -� Ile FEE AMOUNT DUE AMOUNT REMITTED f CASH RECEIVED BY ,DATE PERMIT"NO. f i + +EH 13.24(REV.101831INFO -7Z, EH 14.28 t