86-406 - Laserfiche WebLink

Home Browse Search

APPLICATION.FOR PERMIT — i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i` Triplicate) licate .;;,(Com pfete in p l Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein'describbd. 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. " ... ��"G Job Address _ 1. e) City Lot Size PM .. Owner's Name Address �� C s �[` �n �r� Phone- - r J. `Contractor's Name -I r" s I[3� — C License No. C t{• / Phone - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES 1 00 f DISPOSAL FLD.'6'-"' PROP. LINE /CSO f FOUNDATION �r 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 ❑ Domestic/Private XGravel Pack ❑ Tracy Type of Casing�]!�/;"�Y [ Specifications D<Public ❑ Other il ❑ Delta Depth of Grout Seal i kc Type of Grout r ❑ Irrigation Lf4112-Approx. Depth ❑ Eastern Surface Seal Installed by -QA-2 Repair Work Done ❑ Type of Pump� DktZT H.P. / '25' n State Work Done _C.-J S 9, A,.0=,n9+h ai i0 Well Destruction ❑ Well Diameter Q_._"... Sealing Material Itop 501 Depth JT/� ` Filler Material /Below 501 } TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1�-I available within 200 feet.l Installation will serve: Residence—[Commercial 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 Capacity No. Compartments 3, PKG. TREATMENT PLT. ❑ Method of Disposal to Distance to nearest: Well Foundation Property Line O LEACHING LINE ❑ No. & Length of lines i Total length/size FILTER BED ❑ Distance to;nearest: Well Foundation^ Property Line SEEPAGE PITS ❑ Depth �) # Size Number SUMPS ❑ Distance toynearest: Well Foundation Property Line DISPOSAL PONDS. ❑ I - rl 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. .. ' -- ,., — T -r 1 r � 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 .y 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."x 'The applicant must call for all re uired inspections. Complete drawing on reverse side. 1 S�ignneed Title: I -n o C� .ita�r +y 1�I� Date: FOR DEPARTMENT USE ONLY OC-taC.. �� •�7��-`�� r "5 3 Application Accepted by � �r-G�se� Date 2 Area v .. Pit or Grout Inspection by Date Final Inspection by /ll'�2Date Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621. -- ❑ Manteca 823-7104- ❑,Tracy 8355-6385 a Applicant= Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.;CA 95201 1 . . _ -.. q IFEENFO AMOUNT DUE 't AMOUNT REMITTED ASH RECEIVED BY DATE PERIVIIT"IVO. +EH 13-24(REV.10183) EH 14-26 - iii �/�.VL6 g i