86-202 - Laserfiche WebLink

Home Browse Search

!I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ... 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466=6781 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 F or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin made in compliance wiih San Joaquin County Ordinance No.549 for sewage Local Health District. _23a 5—'/ ZA CA fAl C= City a I dt Size PM Job Address, I Owner's Na e /IR(pY Cr - Address �3 Phone J al Address � License No-9; Phone.. Contractor I �- I TYPE OF WELL/PUMP:--""` NEW-WELLElREPLACEMENT C1 DESTRUCTION ❑ PUMP INSTALLATION 71 SYSTEM REPAIR OTHER El I� DISPOSALF.LD,� `* -"`s'PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �I FOUNDATION AGRICULTURE WELL OTHER WELL- `, SPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial'E: ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1i T e of Casing Specifications ❑ Domestic/Private �❑ Gravel Pack ❑ Tracy yp } ❑ Public �I. ❑ Other ❑ Delta ' Depth of Grout Seal Type of Grout [ EJ --- Appro 3. Depth Ll Surface"Seal-lnst Iled by fff State Work Dona, F t Repair Work'Done El Type of Pump H. _ h a I Well Destruction ❑ Well Diameter Sealing Material (top 501 is Depth Filler Material {Below 50') W TYPE OF SEPTIC WORK: NEW INSTALLATION -REPAIR/ADDITION ❑'DESTRUCTION 0-(No septic sysfem'permitted if public sewer is, G Y available within 200! feet.) S _^ Installation_will-gerve: - Residence-j,_Commereial,__,�,-0ther t f living'units:�— Number of bedrooms ! Jc dA3F 'Water table depth, I CharacteNumber p of soil to a depth of 3 feet: L=_ �_ r-. r SEPTIC TANK ❑ Type/Mfg 7l, A� Capacity — No. Compartments PKG. TREATMENT PLT. ❑ $t FT Method Disposal_ F Distance to nearest: Well Foundation Property Line - { LEACHING LINE y No. & Length of lines ~ Qp � Total length/size O' ,ocr7 I � FILTER BED � ' � Distance toEnearest: WeWellFa+jadation�� Property Line_rid 0_ � SEEPAGE PITS ❑ Depth ' .Size 1 Number r !9 Ll Distance to nearest: Well Foundion Property Line ' SUMPS DISPOSALS PONDS ❑ I I hereby certify that I have prepared thisf 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. lr' 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 t 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 isaissued,I shall employ person subject to workman's compensa- tion laws of California." �- The applicant must call for all r fired,i ctions. Complete drawing on reverse side. . � Date: Signed Title: jpjps FOR DEPARTMENT USE ONLY--" it t Date E Area Application Accepted by A�*� IT 'P Date Final Inspection by —✓Date,[/ Pit or Grout Inspection by T Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Appllcant; Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s _ FEE -AMOUNTiDUE ,AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO INFO y — + EH 13-24(REV.i EH 14-26