86-268 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., S70CKTON, 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. 2— Job Job Address r X47 dG=` i.te tA. i Clry Lot Size PM Owner's Name ress LI_ ( Phone Contractor Address -j,., License Nohl- 23 �Phone r t•�- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER 17) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ; _ DISPOSAL FLD. PROP. LINE FOUNDATION,- AGRICULTURE WELL'' �— .'OTHER WELL _ PITS/SUMPS- " :... JNITENDED USE TYPE OF WELL 'PROBLEM AEA ,CONSTRUCTION SPECIFICATIONS.IiY� Industrial '-El Open Bottom ❑ Manteca YDia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public,' ❑ Other ❑ Delta jDepth of Grout Seal Type of Grout ❑ Irrigation ---Approx. D�h ❑ pastern ♦Surface Seal Installed by Repair Work Done ❑ Type of Pump � t H.P. 0 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ? Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is (y.� available within 200 feet.} V Installation will serve: Residence_ Commercial_ Other ;•� Number.of living units: Number of bedrooms Character-of soil to a depth of 3 feet: �'•• Water table depth SEPTIC TANK ❑ Type/Mfg Ca act p tY No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Dista'Kee to nearest: Well - Foundation Property Line l LEACHING LINE. ","'', ❑.-'.No. &Length of lines - 7 -. otal-length/size- - - - FILTER BED ❑ Distance to nearest: Well Foundation Property Line l SEEPAGE PITS ❑ Depth - Size " Number SUMPS. ❑ Distance to nearest: Well t Foundation Property Line DISPOSAL PONDS ' ❑ - h.. •� a a, _ I hereby certify that I have prepared this application and that the work will be done in accordance with 7San 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." The applicant t c I�fll wired inspections. Complete drawing�orejverse side. Signed X_ •Title: '�t !'d/ .Ds t 6, — ate FOR DEPARTMENT USE ONLY (A/ ' Application Accepted by ( " Date J y '. -x r Asea ` Pit or Grout Inspection by Date Final Inspection by Additional Comments: - t ec 7"A ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409,Stk.;.CA"95201; err( FEE AMOUNT DUE , AMOUNT REMITTED CK INFO RECEIVED BY DATE dti�u r PERMIT' CASH + EH 1324(REV, EH 1426 C, As,