86-1450 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. aJI Job Address City Lot Size PM Owner's Name ddress ��• Bane Contractor 4 i—"/ ABdress License No.*EM1142 Phone 3/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION A gEj0AAt +"5sXWEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �rDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications ElPublic ClOther ❑ Delta Depth of Grout Seal "' Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump SlL H.P. f _ 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 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other }I Number of living units: Number of bedrooms X11 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments . PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property,Line ' SEEPAGE PITS ❑ Depth, DRi Size Number ° SUMPS LlDistance to nea est:f Well Foundation (Property Line_. t 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 rules and regulations of the San Joaquin Local Health District. I ..* F 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 taws of California."Contractors hiring or sub-contracting signature certifies thefollowing: "I certify that in the performance of the work for which this permit is issuefd, I shall employ pergbns subject to wb&man's compensa- tion laws of'California." The applicant s a for Il requirodi spections. Complete drawing on reverse We.,` ;' Signed( Title: f. (Date j ti l FOR DEPARTMENT USE ONLY Application.Accepted y °�- �` Date — , 'Brea Pit or Grout Ins*ti by Date % Final Inspection by nMe Additional Comments: - Ll Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac ti. 1� Y Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY 1 DATE PERMIT`NO. + EH 14-24 ffifY.1/95l EH 1426