86-517 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT r' II SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA F Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) .st�✓� JApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo erein crt ed. T=appation is `'made in compliance with San Joaquin County Ordinance No,549 for sewage or No. 1862 for well/pump and the les and Regulations of the San Joaquin I'Local Health District. Job Address !Y �.' City �� Lot Size � PM 1 r /j: _ '" .: r=� �" �' Address es7 RIs',Sf Z 0 Il 45' Phone lryv ~l ;�Owner's Name Contractor t``�q�+QC � � ddress � /�,a&ALicense No. � rT Phone hTYPE�OF WELL/PUMP: !; NEW WELL 0ll {,,� WELL REPLACEMENT ❑ - DESTRUCTION ❑ t PUMP INSTALLATION J SYSTEM REPAIR ❑ OTHER ❑ l If DISTANCE TO NEAREST: SEPTIC TANK 12 d SEWER LINES Ta DISPOSAL FLD. PROP. LINE i"`""•""`FOUNDATION AG RIC ULTU RE-WE LL=&_1 OTHER WELD- ---ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial # ;K Open Bottom ❑ Monte � Dia. of Well Excavation Dia. of Well Casing S i>' �i.Domestic/Private ❑ Gravel Pack ,. ❑ Tracy Type of Casing Specifications� ❑ Public El 'Other ❑delta Depth of Grout Seal ��8 Type, of Grout ❑ Irrigation �_-GLApprox. Depth", ❑ Eastern Surface Seal Installed by €�Repair Work Done ❑ Type of Pump »t } H.P. State Work Done I Well Destruction. ❑ Well Diameter �� f Sealing Material (top 501 &5AOJl # I Depthh Q } Filler Material IBelow 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION q REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available_within 200 feet.) Installation will serve: Residence— Commercial_ Other Ill 4 Number of living units: Number of bedrooms Character of soil to a depth'lof 3 feet: Water table depth {€ SEPTIC TANK ❑ IiType/Mfg Capacity No. Compartments PKG. TREATIll PLT. ❑ Method of Disposal - Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. &Length of lines Total length/size 4 FILTER SED ❑ Mistance to nearest: Well Foundation Property Line � l s SEEPAGE PITS -_—B-Depth -- __� , SizeNumber ESUMPS ❑ bistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 k certifies the following: "1 certify that in the Derformance of the work for which this permit is issued, I shall employ persons subject to workman's oompensa- F tion laws of California." �p ��- � 42 ^z�p�q The applicant mu scall for allrequiredinspections.��o. a drawing on reverse side. r i� Signed Title: Date: t FOR DEPARTM NT USE ONLY C/ Application Accepted by Date Area r f Pito Gro Inspection b4 Date al Inspection by Date a Additional Comments: ❑ Stk 466-MlXopie di 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Reiurn all -o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO' AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. CASH �yOL^1.�^� + � �1r✓ � . EH 14-26 --'"