86-111 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 3 " 1601 E. WAZE�TON AVE., STOCKTON, CA Telephone {269) 466-6781 PERMIT EXPIRES 'VYEAR 7FROM DATE ISSUED 0 i%- 36J = . (Co'rrtplete in Triplicate)` .g. � .w��T"�� - t•+ � - ..of - "t . i .. .t - —'t�.-- i:'H"'}i :Y�. "r#t,.i. i •? '"4., .� 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. Job Address S 3 X16 i 1 V1 v44 P-J>, _ Ci 1--4 by l` Loi Size '��4"7C ZOO'`p{1/j " Jo tY? _ j Owner's Name' 6L4 24 h17-e as 54U/A/6-1--Address 44��q 4MA)I. LAAe--5—Pk.- Phone -z 2'Ji N Jr Contractor "r12Ptj5 rvL3AAdYre_ss '""-=/ A"iV� "5T/C�tLicense tEo:4�Y� Y7G Phone 971 p TYPE OF WELL/PUMP: NEW WELL ❑"ti; WELL.REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION `"4= AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF'WELL-�--PROBLEM AREA CONSTRUCTION SPECIFICATIONS w I ❑ Industrial ❑ Oper{Bottom ❑ Manteca Dia. of Well Excavation !Dia.,of Well Casing ❑ Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing I Specifications a ❑ Public ❑ Other 1171 Delta, Depth of Grout Seal Type of Grout ❑ Irrigation #' ---Approx. Depth" ,)❑ Eastern Surface Seal Installed by Repair Work pone ❑ Type of Pump H.P. State Work Done L_ Well Destruction ❑ Well diameterSealing Material (top 501 - u- Depth N �+ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW'INSTALLATiON,❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public-tewer is `available"within 200 feet.] Installation.will serve: Residence_ Commercial_ Other tP Number of diving units: !Number of bedrooms T,*J Character of soil to a depth of 3 feet: sWater table depth SEPTIC TANK ❑ Type/Mfg R Capacity i No. Compartments i PKG. TREATMENT PLT P--- iMethod of Disposal r r Distance to nearest: Well Foundation Property Line LEACHING LINE- ❑ No, & Length of lines Total length/size ' l' FILTER BED ❑ Distance to nearest: Nell FoOndation Property Line I S SEEPAGE PITS ti ❑ Depth /0 ' "Size X 1"Z "". Number I , SUMPS ; l" Distance to nearest: Well Foundation 171 �4=1 Property Lines } DISPOSAL PONDS 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 S rules and regulations of the San Joaquin LbFcal Health District. " - t " , Home owner or licens� ed agents signatce ure rtifie5-the-following: "I certify hat in the performance of the work for which this permit is issued; I shall not lI employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signa'ture certifies the following: "I certify that in the performance of the work for which`rthis permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant must call for all required ins ctions. Complete"drawing on reersee side. kk Signed X - v Title:�!ta+�.r-1 "Date: "•Z-!`>f fro FOR DEPARTME T USE ON } Appli tion Accepted by i Date Area Grautln tion b cy e Oate1 Final Inspection by ' Date 7 14.1 Additional Comments: ❑ Stk 466 6781odi 369-3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 Applicant- Return all copies to: Environrtiental Health Pe 1601 E. Hazelton Ave., P.O. Box 2009;'"Stk, CA 95201 FEE AMDUNT D1JP- ; AI OUNT REMITTED CASH -_.-RECEIVED-8y .,.,DATE. PERMIT`NO.- "{ -INFO z - + EH 13-24(REV.3./a 5) EH 14-26 i