86-1077 - Laserfiche WebLink

Home Browse Search

l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 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. ' t Job Address City Lot Size ' PM Owner's Name ress 5-w r J. r 4 Q t 2aDFPhone y7s z 0 via T 111 Contractor � Address_! � �ei_ '^Y+; *..—�—. - License Na: .+Phone TYPE OF WELL/PUMA: N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,.w . PUMP INSTALLATION ION ❑ x+ SYSTEM.REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKi# SEWER LINES 1s � DISPOSAL FLD. PROP. LINE �` FOUNDATION ___•AGRICULTURE WELL OTHER WELL PITS/SUMPS _ . INTENDED USE TYPE OF WELL f PROBLEMAREACONSTRUCTION SPECIFICATIONS ❑ industrial isf ❑ Open Bottom � Manteca >� Dia. of Well Excavation .' Dia. of Well Casing �T • >, EJ Domestic/ M Gravel Pa cki�i Tracy Type of Casing Specifications ❑ Public LIOther'",. D Delta Depth of Grout Seal Type of Grout C r ❑ Irrigation ' _Approx Depth 2 Eastern Surface Seal Installed by-- '_ A* � f Repair Work Done ❑ Type of Pump �,, H.P. State Work p 5-r Well Destruction ❑ Well Diameter f Sealing Material (top 501 Depth �"''�'� Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION C5 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I'A%# .4-vN,I i�jl� available within 200 feet.) Installation will serve: Residence_ Commercia Other Number of living units: Number of bedroom fC Character of soil to a depth of 3 feet: "N, Water table depth ' SEPTIC TANK CDr Type/Mfg `L Capacity-0-0—a— No. Compartments PKC. TREATMENT PLT. ❑ Method of pisp I Distance to nearest: Well f d pFoundation Property Line t LEACHING LINE Wr' No. & Length of lines !`-w To al length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i 1- 1 i SEEPAGE PITS ❑ Depth Size I umber SUMPS ❑ Distance to nearest: Well Foundation PropeLine ' DISPOSAL PONDS ❑ t 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, ani rules and regulations of the San Joaquin Local Health District.' � I, Home owner or licensed agent's signature certifies the following: permit is issued, I shall not 9 g g: "I certify that in the performance of the work for which this orkman's compensation laws of California."Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject to w certifies the following: "(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." `�'A '� # The applicant must call for . quired inspections. Complete drawing on•reverse side. i Signed ,r�-rs�� 1t,Gl?�>_> Title: Date: _ " D R DEPARTMENT USE ONLY r Application Accepted by Date Area ' n i Pito rout Inspection by CZ�.Aa .\_LaiaAti D B Final Inspection by alMDate Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ 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 I FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-241pEV,tills} EH 14-28 S/—7/'?