86-626 - Laserfiche WebLink

Home Browse Search

A U-1----A - 4- APPLICATION FOR PERMIT -x IS"7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67,91 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. Job Address C7 City ti-tot Size PM 3� i Owner's Name 1& ST _ & Address Phone Contractor's Name �' L License No. /C Phone �� p TYPE OF'WELL/PUMP: NEW WELL,)/ WELL REPLACEMENT ❑ DESTRUCTION ❑ / ;7� 11 PUMP INSTALLATION-��- SYSTEM REPAIR ❑ OTHER 17 —70 / bISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I/ FOUNDATION-- AGRICULTURE WELL OTHER WELL PITS/SUMPS' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,1 ❑ Industrial 4 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private AGravel Pack ❑ Tracy Type of Casing_ e to Specifications I` ❑ Public I ❑ Other ❑ Delta Depth of Grout Seal LG] Ty a of Grout ❑ Irrigation /4kfApprox. Depth Eastern Surf a Se I Installed by Repair Work Done ! Ig'--Type of Pump H.P. AW State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 J Depth Filler Material (Below 501 f `� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK II� ❑ Type/Mfg Capacity _ No. Compartments / PKG. TREATMENT,PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line { a}t LEACHING LINE ❑ No. & Length of lines Total length/size i I 1 FILTER BED ❑ Distance to nearest: Wall r Foundation Piopercy Line. j I SEEPAGE PITS ❑ Depth Size <—Number SUMPS '❑ Distance to nearest: WeII - Foundation Property Line DISPOSAL PONDS:. `❑ I hereby certify that'I have prepared this application and%that.the.-wark 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 agents signature certifies the following: '9 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 app' u call for all requ' inspe ons. Cc ete drawing on reverse side. { Signed y .. Title: Date: Q `L� r 53FOR DEPARTMENT USE: ONLY y Application Accepted by' Date -/Z�o Ar ' Pit or-Grout lrispel tion tiyl�"' •- � Date 6 �� Final Inspection'by Additional Comments:. El Stk 466.6761 .l�.. ❑ Lodi 369-3621 ❑ Manteca 823-7104 y❑'Tracy X835 6385, I\ f_3 Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE `v INFO 4 AMOUNT DUE AMOUNT.REMITTED CASH RECEIVED BY DATE @PPERM`IT NO. +EH 13-24{REV.10/831 EH 14-26