91-1036 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA 4 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IE (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. f Job Address 0-1�15 City Lot Size attPM Owner's Name ( Address t o Phone r- �-!J , s� �1 f Contract f r Address r=��altI.—�ti C�:QCt�� License N14?29.0 2 to Phone — 0S TYPE OF WELL/PUMP: NEW WELL ❑ '% ECL REPLACEM-ENT ❑'',;" DESTRUCTION ❑ PUMP INSTALLATION ❑ 3 titM''_Fil %A1R ❑ B OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD-•- PROP. LINE f , FOUNDATION AGRICULTURE WELLOTHER WELD PITSISUMPS I1 INTENDED USE TYPE OF WELL PROBLEM AREA —CON STRUCT10N^SPECIFICATIONS ` 1, ❑ Industrial../-'-4 ❑ Open Bo}tom .� ❑.Manteca7l'`'. QDia. of Well Excavation Dia.`of Well Casing II ❑ Domestic/Private f 171 ale ❑ Tracy Type of Casing ,Specifications, , Public r IF] Other j F1 Delta Depth of Grout Seal f Type Grout _ I Irrigation >- Approx.,Depth . 'I,(`Eastern _ Surface Seal Installed by Repair Work Done ❑ " Type of Pump H. State Work Done ' r v *; '1^. Well Destruction ❑ Well Diameter dam' Sealing Material Qbp-50')_ Depth/ _" <' Filler Material (Below 501 STYPE OF SEPTIC WORK: ,NEW INSTALLATION REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic'system permitted if public sewer is { F/ available widiih'200 feet.) 1/ Installation will serve: Residence Commercial_,f�ther 1 r fly ,_fl Number of living units: Numbero rooms Character of soil to a depth of 3 feet:' r - Water table depth 100 ` SEPTIC TANK 41� Type/Mfg Capacity .. No. Compartments f PKG. TREATMENT PLT. ❑ [ / Method of Disposal Distance to nearest: Well Foundation= Property Line r ti LEACHING LINE No. & Length of lines 0 Total Iengtliisize 'S x r i l ay. 's'�y\ � _• .:. .. -J»k+.�'�;r^,M ,. FILTER BED Li1 Distance to nearest: Well JW Foundation Property Line"�L—_' r SEEPAGE PITS` ' Depth Size dumber SUMPS [7istance to nearest: Well 1�Q_ Foundation to Property Line DISPOSAL PONDS ❑ t 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 t 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." f The applicant mu II for all i recliNspections. Complete drawing on reverse sidef) F Signed X Title: VT. Date Lli m- OR DEPARTMENT USE•ONLYt----.—.. i 5 ' Application Accepted by Date Area - ; .'.. . L tom.>.,�.w#�!�� f� i Pi or Grout Inspection by - .DatQ , /-Final Inspection.by `^�T Date �� j Additional Comments: s f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 N E&k4I FEE AMOUNT DUE i AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO .,EH 13-241REV.1/P51 $ a / EH 14-26 �•d) k