86-1167 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 LIP PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 6 F 327 (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. `/ !� �C C Job Address �� /v! ��Td�� `9 City Ld Lot Size a �fi PM 5 Owner's Name �2 Address 5�� Phone �r Contractor, � � _ �Address � eCl' License No. Z 6 Phone TYPE OF WELL/PUMP:�-J NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ 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 _6'Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by f ffepair,,lNork Done ❑ Type of Pump i� H.P. f a~State Work Done ell Destruction ❑ Well Diameter Sealing Material ltopL5q) ow,5(1' Depth Filler Mater) i IBeli �= TYPE OF SEPTIC WORK: NEW INSTALUTION ❑ REPAIR/ADDITION DESTRTION ❑ INo septic system permitted if public sewer is N J available within 200 feet.) Installation will serve: Residence v' -Commercial_ Other Number of living units:–1— Number,of bedrooms '2 Character of soil to a depth of 3 feet: I C"7 Water table depth SEPTIC TANK ❑ Type/Mfg r &paci4 No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines 60 FT Total lengthlsize FILTER BED ❑ Distance to.nearest: Well Foundation Property Line SEEPAGE PITS Depth _Z�� Size_:33 Number f " SUMPS ❑ Distance to'nearest: Well FoIndation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will b done)n 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_th y_ ia1 rformance of the work for which this permit is issued, I shall not employ any person in such manner as to became 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 whkh-this permit is'issued,I shall employ persons subject to workman's compensa- tion laws of Californ' The applicant mu re 'red in ns. Complete drawin on reverse side. Date: Signed itle: R DEPAR ENT USE ONLY -f6 Application Accepted by Date Area r f Pit or Grout inspection by � � Date Final Inspection by Date c Additional Comments: r11 " ❑ Stk 466-6781 ❑ Lodi 369421' 1t] Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Enviro til 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 CASH f� Q + EH 13-24{REV.t/e 51 �,Q t Q ALJ [-is`p p Ips/I tp( EH 14-29 t _ �rr