86-380 - Laserfiche WebLink

Home Browse Search

t',& APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,s STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED '" F` - � I {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 Ryles.and Regulations of the San.Joaquin Local Health District - Jah Addtess City' -7*AJt Lot Size PM Owner's Name '(2&r7& Addresses -';Z�ZE -=Phone' Contractor d&J&Z ZL l __Address I.-OX La/LL_ZAIL) Jf License No. 76 Phone g�1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. 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 A El Other [ Ll Delta Depth of Grout Seal Type of Grout 7� El Irrigation k ---Approx. Depth ❑ Eastern Surface Seal Installed by y' Repair Work Done ❑ Type of Pump H.P. State Work Done { Well Destruction j ❑ Well Diameter Sealing Material (top 50') 11 j aterial (Belo 50' Depth Filler M ] TYPE OF SEPTI,G'UVORK: NEW INSTALLATION ❑ REPAIR/ADDITION Rr 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 1 s+ < Character of soil to a depth of 3 feet: Water table depth. SEPTIC TANK Type/Mfg` l� �- - P1 _ Capacity f�-crC7 No. Compartments y t i -PKG. TREATMENT PLT. ❑ Method of Disposal \, Distance to nearest: Well _. Foundation. /4 Property Line Z� ' 4 E ` LEACHING LINE No. & Length of lines --j� Total length/size FILTER BED ❑ Distance to nearest: Well -.Foundation-- Property Line 'SEEPAGE PITS Depth t5 Size, --X'l * t Number 1 SUMPS ❑ Distance to nearest: . Welt,-'5-Q Foundation Lai '4:f' Property Line IOzTt 'DISPOSAL PONDS ❑ A ,I hereby certify that I have prepared this application and that the work will k e 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 tlie�'Wrform`ance 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." Contractors 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." �; V� ' The applicant must call for all required inspections. Complete drawing on reverse side. a; Title:— � Date: --44/- FOR � 'Signed - FOR DEPARTMENT U5E ONLY C� l < �'�y1 ;4ppticatiotl;4cc """"" epted'by �='�^�� .— Date Area Pit a5- Grout Inspection by � Date Final Inspection byDate l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 '❑ Manteca 823-7104 0 Tracy 835-6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;S&,1CA 95201,"- -FEE— -AMOUNT-DUEI- 5201;_FEE,.---:AMOUNT-DUET— AIVIOUNT-REMITTED"' CASH— RECEIED .� V6V � DATE� PEftMIT"NO,e INFO �'- + EH 13-244REV.1/a s) � p "K—L, a 3� F EH 1426 r