86-935 - 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 Rules and Regulations of the San Joaquin Local Health District. c Z Lcam. Job Address C City Lot Size PM Owner's Name Address L 7-2` one �r�` -32 Contractor f� CP,4ddress� �"�' License No. �2hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ + DISTANCE TO NEARE_ST_:_SEPTIC TANK .SEWER LINES _ DISPOSAL FLD. -P$OP_LINE FOUNDATION AGRICULTURE WELL OTHER_WELL PETS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial .171Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0_Tracy Type of Casing Specifications ❑ Public '=J ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump'm H.P. State Work Done g Well Destruction. ' ❑ Well Diameter _ Sealing Material (top 50') 0 Depth I Filler Material (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION� 'REPALR/ -DITION DESTRUCTION El septic system permitted if public sewer is available within 200 feet.) pp Installation will serve: ResidenceCommercial_ Other Number of living units:-Lj-- Number o bedro ms- Character of soil to a depth of 3 feet: -1 Rte Water table depth ' SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments rj PKG. TREATMENT PLT. ❑ Method of Disposal /( Distance to nearest: Well Foundation Property Line S LEACHING LINE ❑ No. & Length of lines Total length/size C FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number 0 SUMPS ❑ Distance to nearest:' Well Foundation �s Property Lined ,1 DISPOSAL PONDS Cl 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. I 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 I 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-. k tion laws of California." The applicant st call or I re inspections. Complete drawing on reverse side. _ Signed _ _ _. _ _ Title: Date: FOR DEP TMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date F' I Inspection by We % Additional Comments: J ~dam ❑ Stk 466-6781 L i 3621 ❑ Manteca 823-7104 ❑ racy 83 Applicant- Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, SOCA CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO �y a a EH 13-241REV,1/85) EH 14-25