86-496 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA f Telephone (209) 466-6781 _ PERMIT EXPIRES 1 YEAR FROM DATE,ISSUED k (Complete in.Tripli.cate) �,k; 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 5 U �'C-: r �a 11 CvCity Lot Size PM �, ,,� II Jrr� UIa�S(�cr Owner's Name C�LT ►JS� Address ' ""` rrT QM Phone � �`��,� l eA 4r S' Zbs-o4?6 f Contractor ' ._ SAjf« + Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 1-1, WELL REPLACEMENT LlDESTRUCTION F-1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9 Aao ITov_ju� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELLS-, OTHER:WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j Industrial AmtpCi�o� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation L l wt[� Dia. of Well Casing ❑ Domestic/Private (] XGravel Pack ❑ Tracy Type of Casing - Specifications 1-1Public ❑ Other L) Delta Depth of Grout Seal 3 Type of Grout CeAu A* rox. Depth ❑ Eastern Surface Seal In b ''4'l�r��1! gv 1 ❑ irrigation &>.APp y"` � i Repair Work Done ❑ Type of Pump A r LS+ H.P. t State Work Done fWell Destruction ❑ Well Diameter Sealing Material (top 501 Depth too; filler Material (Below 50`) TYPE OF SEPTIC WORK: NEW INSTALLATION-11 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is v; ^available within 200 feet.) Installation will serve: Residence_ Commercial_ Other t _ 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- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE v ❑ No- & Length of lines Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS ❑ Depth Size 1 Number I SUMPS ❑, Distance to nearest Well Foundation Property Line _DISPOSAL-PONDS ❑., s t.- -% {.s-: . - - °r �, -�^ •TM--� _: 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, an 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, 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 following: "I certify that in the performance of the work for which this permit is issued,Lshall employ persons subject to workman's compensa- tion laws o alifornDate:,v The appli s .c or all r ired spe ions. Complete drawing on revers ide. Title: S OCl�^� Signed DEP RT N E ONLY Application Accepted br Date Ar y , Pit or Grout Inspec y s — Final Inspection b Date Additional Comm an ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ acy 6385 �✓ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2(109, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 1324IREV.5ia51 � �0 `"tel CI.(p EH 14-26 777TTT - _