86-783 - 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 Regulatior>g of the San Joaquin Local Health District. �J Job Address 17 / ✓ r V CiAlf)( � !f 7Z�_��'� tyLot Size PM Owner's Name ,( - I r f 4 Address }��=A7Phone 0� Contractor��Ot �� Address D License No.�jPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DEST"UCTION ❑ 'X" _ PUMP INSTALLATIP ON ❑ _. SYSTEM AEPAIR ❑ .q OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK � 0 SEWER LINES DISPOSAL FLD. Irff PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A rldustrial ❑ Open Bottom Manteca' Dia. of Well Excavati Dia. of Well Casing r ElDomestic/Private' 'Gravel Pack ❑ Tracy Type of Casing Specifications I A7 P ✓✓✓Xpublic ❑ Other 13Dllta I Depth of Grout Seal, �I Type of Grout I❑"rrigation �pprox. Depth ❑ East Surface Seal Installed by VW i Repair Work Done p.! Type of Pump / H F� S te/Wor Done Well pestruction � We Diameter {2�- `�r�� Sealing Materia!Ftop 50') Ma fklr 4e, rnp4l� 0 epth n�7') Filler Material (Below 501) t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I 1 4 " f / available within 200 feet.) Installation will serve: Residence. Commercial-1 r :A. Number of living units: Number of bedrooms Charact4 of soil to a depth of 3 feet: "�.. Water table depth r .. ,._ate :..l. y -SEPTIC TANKZ "Q;'Type/Mfg ate �i�} ._ Capacity No. Compartments PKG. TREATMENT PLT'❑-. €'g Method of Disposal Pistanc(i.to nearest: Well Foundation Property Line LEACHING LINE\ ❑ No&Length of lines 1* � Total length/size FILTER BED 173 Distance to nearest:'s (Well)I Foundation Property Line SEEPAGE PITS _E3Depth - Size Number 7 SUMPS ❑ Distance to nearest: 1Well Foundation Property Line DISPOSAL PONDS ❑ s A f 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. 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." to *IJ - The applicant for I red inspections. Complete drawing on revs side. ,. Signed Title: _ . Date: _I5-1 FOR DEPA TMENT USE ONLY /j Q Application Accepted by r"' Date / ��u Area Pit or Grout Inspection by ate L ifnal Inspection by 1 v Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantes 923-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 w FEE CK 0 INFO AMOUNTDUEAMOUNT REMITTED CASH RECEIVED BY DATE APERMIT N0. + EH 13-24(REV.f/a6) �!/. V EH 1428