86-411 - Laserfiche WebLink

Home Browse Search

��' J�� °' 'tet•• _ ' "' � � � y` � � �_ � _— _ :rr�-_.••, vt t � APPLICATION FOR PERMIT . f � —`*SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA v Telephone {209} 466-6781 tom' 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. . 1 r �r ' Job Address W / 1/V��To,'J `\`Ir, a6-K7-a , City Lot Size PM- Owner's..Na X/" ��Jn Ff; I�IZ/ �Address��Q• L�OX �I IiQFI� � Phone, 11-0—tl actor.• Address =d SOX o/! License No. 6g g Phone /' / TYPE OF WELL"/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ e PUMP INSTALLATION R t' ".` ~:'` k" SYSTEM'-REPAIR CIOTHER ❑ „. DISTANCE TO NEAREST: SEPTlC TANK /DO SEWER LINES A� T DISPOSAL FLD. PROP. LINE ) FOUNDATION _ AGRICULTURE WELL__ OTHER WELL PITS/SUMPS') O iINTENDED USE TYPE�Oi«WEL•L`-""PROBLEM-AREA'CONSTRUCTION SPECIFICATVS(FIndustrial ❑.,OpenBottom. ❑ Manteca Dia. ofW II Excav ti n'� Dia. of Well Casing❑ Domestic/Privates Gravel Pack ❑ Tracy 'Type of'Casirig Specifications ❑ Public q ©'Other ❑ Delta Depth of Grout Seal +�6 z f p Type�f Gaout � �Ai!T i ❑�I�rigation 3$�'./` pprok-4Depth7`❑ East ren r�Surface Seal Installed by t JE 7"F_IQ [)+Q I z`�(, Inf(� { Repair Work Done ❑}' yT pe of Pump d*7 �H,P. J 1 State Work Done Well Destruction ❑ Wel! Diameter, Sealingfhll $ y j t. Caterial,{top ) ! - Depth- —Filler_Material (Below-50'i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAiR/ADDITION ❑ DESTRUCTION ❑JNo septic-systerri permitted if public sewer'-is:' ""-^`— t -•?wa i. =available within-200'feet:) Installation will serve: Residence— Commercial_ Other v6 f.� y "t Number of living units: Number of bedrooms Character i of soil to a depth of 3 feet: l . I Water table depth's'" SEPTIC,TANK ❑ Type/Mf I ' 9 _ Capacity No. Compartments PKC. TfEATIUIEIVT Pf T' j Disposal - � p�S.y -� � Method of I Distance to nearest: Well Foundation I Property Line 5 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:. Well Foundation Property Line { i t SEEPAGE PITS ❑ Depth T Size Number I SUMPS ❑ Distance to nearest:. Well Foundation Property Line DISPOSAL PONDS ❑ i 1 ,',, n r i hereby certify that I have prepared This-application and that tfie.�rk will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin-Locals alth bistrict. Home owner or licensed agent's signature,certifiettherfoilowingrl"I certify that in the performaricVof the work for which this permit is issued, I shall not employ any person in such manner as to'become subject t6Vvork nan's compensation laws of California." Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the perforrhahce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion',IaGvs of California." f The;applic nt mus f r lIjApuired inspections. Complete.drawing on reverse side. 1' Sign d / ' G Title: 0/�/TRADate: 1 RFOR D ART ENT USE ONLY Application Accepted b Da4te �� Area { 1 n [7 Pit or Grout Inspection by � Date '0 Final Inspection by J Date 1 A itionil Comments: l (T- Stk 466-6781 ❑ Lodi 369 3621,,,, �-❑.Menteca_823-7104 L1Tracy 835-6385 pplicant- Return all copies to: Environments! Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'MO. INFO_ CASH. + EH 13-241REV.tia51 Vv' � �-� �; /y `w ; EH 1428 l� J • C?J T ,�._ �.a QCT-- 1 C�