86-997 - Laserfiche WebLink

Home Browse Search

b, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT COD 1601 E. HAZEL T ON AVE., STOCKTON, CA 60Telephone (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. . �l Job Address I - bil- J 06d, City Lot Size PM Owner's Name Address cZ q 444 hone .. ' ..32 227-(P Phone,367- a,vv Address`� � License Nn. , TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK-,. - SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE raj_; TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public- ❑ Other ❑ Delta Depth of,Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern.. Surface Seal Installed by Repair Work Done ❑! Type of Pump H.P. State Work Done Well,Destruction ,❑ Well Diameter Sealing Material (top 501 Depth L______FAler Material (Below 501 TYPE OF SEPTIC-WQRK: NEW INSTALLATION Ok REPAIR!ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is a t available within 200 feet.) Installation will serve: Residence' -Commercial Other Number of living units: Number of be ams ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Q Method of Disposal J Distance to nearest: . Well Foundation Property Line LEACHING LINE [Er-No. & Length of lines yr? _ 7D .fin Total length/size /6 Z r � FILTER BED ❑ Distance to nearest: Well /©O� Foundation Property Line SEEPAGOr E PITS_ DR Depth a Size td _ _ Number SUMPS 13 Distance to nearest: Well/SIO Foundation 3O� Property Line DISPOSAL PONDS ❑ 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, 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicantst call fo re uired inspections. Complete drawing on reverse si Signed Title:— \J.P I Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by ate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63&5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO Qom, "� + EH 13.24(REV.U55) ►Q� `-'""�� EH 14-28 f