86-1198 - Laserfiche WebLink

Home Browse Search

! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL"HEALTH DISTRICT 1601 E. HAZE T 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 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. �* •' - t �• 4 I Job Address ,v'�'r,C.r.a : '�--6L+h y City 'f IQn �ot Size t PM ' r 4- �1 Owner's Name IVR'j—LAvddres S�n-� - �a� 3 Phone Contractor Address License No i Phone s TYPE OF WELL/PUMP: NEW WELLi D- " i;•VWELL REPLACEMENT .❑ DESTRUCTION ❑ S .:. l PUMP INSTALLATION 7 � SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ° { sSEWEfi LINES DISPOSAL FLD. PROP.'LINE `= '• trr-;<'; :FOUNDATION AGRICULTURE WELL OTHER WELL ¢ PITS/SUMPS i INTENDED USE , i i .TYPE OF WELL RP OBLEM AREA CONSTRUCTION SPECIFICATIONS ❑,Industrial d ❑ Open Bottom ❑ Manteca E"""� Dia. of Well Ezcayation a- - J Dia. of Well Casing .❑ Domesti'c/Privatb.i�)J l7 Gravel�,Packs ❑ Tracy y Type-of Casing ISpecifications '. ❑ Public �❑ Other ❑ Delta 'k _2 De th of Grout Seal type of Grout - ❑ Irrigation l�+y ' ��f"_Approx. Depth ElEastern'i '�,-- Surface Seal IrInstalled by , Repair,Work Done ❑ Type of Pump P *�: State Work Done Wellt'pestruction '' D 'Well`Diameter Sealing Material Itop 50'1 Depth , Filler Material lBelow 50:1 w. t.,. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑'(No septic system permitted if public sewer is U i ��available within 200 feet,l { k Installation will serve: Residence �Commercial Other Number of living units: Number of bedroom;, ' Character of soil to a depth of 3 feet: �� Y Water table depth"_- 'T1 SEPTIC TANK ❑ Type/Mfg ri a Capacity No. Compartments j PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines otal length/size - FILTER BED Distance to I nearest: We! —N _ Foundation Property Line SEEPAGE PITS ❑ Depth - Size Number SUMPS ❑ Distance to;nearest: Well Foundation Property Line DISPOSAL PONDS ❑ !1 - 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 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." i The applicant mu call for all requ'ed in ctions. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by + Date � Area 0c Pit or Grout Inspection bDate Final Inspection by �CL1LYi[st Date Additional Comments: I d r ladA iA M �1 ce , ❑ Stk 466-6781 ❑ Lodi 369 ❑ Manteca 823-7104 El �re, Tracy 835-6385 01 cor'e b Ile Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Stk., A 95201 y "rJ IEEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY. DATE PERMIT ND. i CASH o o Q +EH 8-24(REy.1/65) � E14114-26