86-258 - Laserfiche WebLink

Home Browse Search

I I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA a Telephone (209) 466-6781 F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED~ .(Complete in Triplicate)_t 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 y24 City Lot Size t'a�� PM- f Owner's Name `� &�I41?�LJ Address Phone Contractor ddress0 — ' ^0 _ Phone 7 License N.14 i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER "❑ \v DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINES FOUNDATION AGRICULTURE,WELL ! OTHER�WELL PITS/SUMPS . i INTENDED USE TYPE OF WELL PROBLEM!AREA,,CONSTgd&,TfOri�SPECIF_ICATIONIS ❑ Industrial ❑ Open Bottom O Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑-Tracy 9 Type of rasing '�! Specifications 3 Y ❑ Public ❑ Other '�Delta�,; �Depthi of Grout Seal `� r Type of Grout ❑ Irrigation �Approx. Depth ❑ Easterrn �SurfaceFSea stalledr b'y 1 i, � Repair Work Done ❑ Type of;Pump � �. �"�.Y H.,p,.a:,..� �f� .,. State Work Done Well Destruction ❑ Well Dia Diameter fes' �""" i �5ealing Materral (top 501= —7 i Depth V S ~ FillAlaterial (Below 50) -i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADphTr QN }DESTRUCTION ❑ (No septic system permitted if public sewer is 'O available within 200 feet.i Installation will serve: Re encu_ C ommercra -Other I *� I Number of living units: Number of°bed dms j 1 i >` — Character of soil to a depth of 34eet:` / 4 _Wate table depth SEPTIC TANK ❑ Typ Mfg ` y 0. ompartments 1 PKC. TREATMENT PLT. ❑ _ ' f� KlIethod of Disposal Distance to nearest: 'Well 4 Foundation: 1 Pr perty�Line LEACHING LINE ❑ No J& Length of line's T tal length/siie r. FILTER-BED F ❑ Distance to nearest:- all Foundation Property Line/d � n !` = yj SEEPAGE PITS ❑ Depth Size .i( umber tee; r SUMPS _ .71 Distance to nearest: Well „_Foundation Property Line DISPOSAL PONDS 11j 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 Loci 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 mannek 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 pe�ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i, The appli t mus all for req red in ctions. Complete drawing on reverse side. L �..„ ,F...� .. �. Signed s; Date: JOR, EPARTMENT,U_SE ONLY Application Accepted by Data Area —�.. Pit or Grout Inspection by ' Date FinalInspectionby i `k. Date' Additional Comments: k ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-&385 k Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 '? {f FEE AMOUNT DUE �+ AMOUNT REMITTED CK RECEIVED BY DATF PERMITNO. INFO CASH + EH 13-24'(REV.iixsl .CO VV EH 1428CAP