86-650 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. 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. g�, dc.tlr2LwA-y 9S+AA15S- � Job Address �(�� qn i Lv r cr y City =� of 5170 Owner's Nam Address4__21 , Lf/ hone Contract 1.4 Address A0 7 / License No.. 9z Phane �' OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEARE PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL M AREA CONSTRUCTION.SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Specifications oq ❑ Public ❑ Other ❑ Delta Depth of Grout Sea Type of Grout ❑ Irrigation �4pprox. Depth ❑ Eastern r Surface Seal Installed by b Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material [top 50') Depth Filler Material 1Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is S - available within 200 feet.) Installation will serve: R�stde¢nce_ Commercial,2 Other Number of living units: �'",,Number of b'drooms 3 / Character of soil to a depth of 3 fbet: W _ Water table depth Jr SEPTIC TANK 1W Type/Mfg 4 Capacity 0O No.-Compartments -- PKG. TREATMENT PLT. ❑ +. Method of Disposal �`, e Distance to nearest: Well_..._�U Foundation_- /0 Property Line�_ , LEACHING LINE Vo. & Length of lines d Total length/size Q K FILTER BED ❑ Distance to nearest: Well Foundation � _.._ Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 's 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.' ._4 . Home owner or licensed agent's signature certifies the following:9 g: "1 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-contractNng 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 must call for a equ' d inspections. Complete drawing on reverse Signed X V-6Title: Date: u FOR DEPARTMENT LLS ONLY Application Accepted by Date i9 � Area �it or Grout Inspection by Date _ Final Inspection by /�}"� Date 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 FEE INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT'NO. + EH13-241flEV.I/115) EH 14-M