86-285 - Laserfiche WebLink

Home Browse Search

. - - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 ExHAZELTON AVE., STOCKTON, CA Telephone {269) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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. t .. Job Address /v , ��G? x�/ ' City Lot.Size M V {yep µ PM Owner's Name Address Phone syS. !nte• Contractor, ",AIS yV/} Address JW License No. Phone TYPE OF WELL/ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _7_— SEWER LINES DISPOSAL PLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSG,SUMPS INTENDED USE h TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1°1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack )d Tracy Type of Casing Specifications t ❑ Public ❑1 OOgPer ❑ Delta Depth of Grout Seal Type oflGrout ❑ Irrigation 'jLApprax. Depth, ❑ Eastern Surface Seal.Installed by �Q ,� Repair Work Done ❑ Type of Pump H.P. State Work Done ` Well Destruction Well Diameter --�� Sealing Material (top 501 j Depth Filler Material (Below 501 ,n TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ 1No septic system permitted if public sewer.is t available within 200 feet.) V Installation will serve: Residence i Commercial_ Other UJ Number of living units: - Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line J- LEACHING LINE ❑ No- & Length of lines Total length/size _f FILTER:BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS y ❑' Depth Size Number ' SUMPS Ll Distance to to 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, an rules and regulation's of.the'San Joaquin Local-Health District._ a 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in theperformance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of California." .. r '''' <V The applicant c Il f all i d inspections. Complete drawing on re erre ide. ai Signed.X itle: Date: DEPARTMENT ONLY Application Accepted by .` Date �,��,,� Area !�� Pit or Grout Inspection by Dade—� Final Inspection by � � ' Date Ad 'tional Comments: III lla `� kiC]�t i UUUr Stk 466-6781 _ ,❑ Lodi 369-3621 ❑ Mantecli B23-7104 ' ❑ Tracy 835-6385 frr t App i ant - Return all copies to: Environmental Health Permitervices 1601 E. Hazelton Ave., P.O. Box n202Stk:, CA 95201 FEE -AMOUNT-DUE--"`A-MOUNT-REMITTED Y CK' J---iECEIV 4DATE PERMIT'NO. INFO CASH r, + EH-13-24 MEV-119 51 -E 14-28 ..-