86-519 - Laserfiche WebLink

Home Browse Search

4 kr APPLICATION FOR PERMIT 1 SAN JOAO.UIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL T ON AVE., STOCKTON, CA l `Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR ,FROM SATE ISSUED ` s 4 {Complete, in Triplicate) and/or install the work herein described. This application is Application is hereby made to the San Joaquin Local Health District for a permit to construct 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. _ r .y Y y AG t LuS 2}w ' Y F• . City l Lot Size f PM �.. Job Address �O _ r✓ 1,�C. � - �� Phone r Address j . Owner's Name Contractors — - . Or Kr�_MPhone Address License o. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ xg" OTHER ❑ 5YS PUMP INSTALLATION ❑ DISPOSAL FL'D._ ' PROP LINE:r� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I PIT$/SUMPS FOUNDATION ' AGRICULTURE WELL OTHER WELL r '' TYPE OF.WELL. PROBLEM AREA 'CONSTRUCTION-'SPECIFICATIONS ) :. INTENDED USE fit,, Dia. of Well Casing ❑ Industrial e ❑ Open Bottom ❑ Manteca Dia. of Well Excavation {t Specifications r Type of Casing - ❑ Domestic/PriVdte r ❑ Gravel Pack El Tracy Type oYGrout ❑ Other t ❑ Delta - Depth of Grout Seal Y I. ❑ Public ' i } ❑ Irrigation. �pprox: Depth ❑ Eastern Surface Seal Installed by H P State Work Done_ P! Repair Work Done ❑ Type of Pump Sealing Material (top 50'1 Well Destruction ❑ Well Diameter Filler Material (Below 50'1 i 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No. ptic system, hin emitted if public sewer is 6, t:..avail4 Installation will serve: Residence Commercial_ Other k ua Number of living units: t Number of bedrooms 1Naier'table depth' Character of soil to a depth of 3 feet: x �I ✓ Capacity = No'Compartment SEPTIC TANK ❑ Type/Mfg.. - Method of Disposal PKG. TREATMENT PLT. ❑. Property Line Distance to nearest: Wel 6V Foundati,A. /, Pe y I I`3 'Tott al lengthlsize'� LEACHING LINE l No. & L'ength of lines + Gr9 Foundatibn`��-Property Line FILTER BED ❑ Distance to nearest: Well :I Size Number ❑ Depth.I `_,0 ; SEEPAGE PITS . 'Property Lane SUMPS Foundation z ❑ Distance to nearest: -Well � _4 3 DISPOSAL PONDS ❑ I hereby certify that l have prepared this application and that the work will be done in accordance with^San Joaquirrcounty 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 signature shall not ion employ any certifies the person rn such 11 certify ert f manner tea as to n the corn mance of t I the work for which this tperm this issued,of fI shall'ernpkoy persons1suti ect to workman'ring or s sub - following: y i tion laws of California." q 4 The applicant must call for 1 re 'red inspections. Complete drawing on reverse side. y� �� F Date: Title: / Signed X I" FOR EPARTMENT USE ONLY r �' 19- . t Area L Date � y' Application Accepted by Final Inspection by Date—_ ` Pit or Grout'Inspection by Date - . b Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211. ❑ Manteca 823-7104 ❑ Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a : t CK.. .mow n 3:RECEIVEQ-Sy '' DATE -' PERMIT'NO. FEE- ..-,-AMOUNT DUE- > =-AMOUNT-REMITTED" CASH _.�.. INFO + EH 73-24(REV"I/A'51 - '"�© ....... .. - — .....�.�.,a.. ....+_�--.• .d-...F�.��..-�w---- ��i�'�t- ^�l w EH 1429