86-370 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT w " SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. -HAZE�TON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES I .YEAR FROM DATE ISSUED (Complete in Triplicate) a 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 7 0/ A V—(olep �-y <,< Job Address f /lo /.//7 - /7 City Aj Lot Size PM Owner's Name ,i11 Address �] 7 4C�CJ�tST I�2/9/ Phone } Contractor's Name N C nse No. �o & \P,hone 80: TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C( SYSTEM REPAIR ❑ OTHER ❑ s'eel,l1 DISTANCE TO NEAREST: SEPTIC TANK ��` SEWER LINES �� DISPOSAL FLD.� PROP. LINE 1 FOUNDATION _�-1 AGRICULTURE WELL A3LQ_!L'OTHER WELLAbkJ�-_- PITSI.SUMPS�ax� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing `4 ❑ Domestic/Private Q�'Gravel Pack ❑ Tracy Type of Casing -r_(�4- Specifications +\ r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1. Type of Grou " } ❑ Irrigation --Approx. Depth ��E�Eastern Surfac Seal Installed by Repair Work Done W Type of Pump <92it5&I H.P. State Work Done Well Destruction ❑ Well Biometer Sealing Material (top 50') ' Depth l Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is " [ j available within 200 feet.) Installation will serve: Residence " Commercial—{ Othpr01. Number of living units: Number of bedrooms." Character of soil to a depth of 3 feet: _ I i _ _ - Water table depth I SEPTIC TANK ❑ Type/Mfg 4. { Capacity No. Compartments PKG. TREATMENT PLT. ❑ s Method of Disposal Distance,to nearest: .Well � Foundation � Property Line LEACHING LINE 7 No. & Length of lines 1 t y ( Total length/size A 1 i FILTER BED I] Distance':to nearest:.- "Well Foundation—_" Property Line SEEPAGE PITS ❑ Depth 1 Size 1 t "Number -i... E SUMPS ❑ Distance nearest: Well Foundation Proper# Lin , 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. . 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 l ` employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa-`- tion laws of California." The applicant call for all required inspecti Complete d wing on everse�side. Signed Title: �� '^ ��+ / a Date: X d. FOR DEPAR MENT USE ONLY vy Application Accepted by v" Date Area Pit or Grout Inspection by ell�{ Date Final Inspection by9 Date. Additional Comments: r ❑ Stk 466-6781 L7 Lodi 369-3621 anteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'`NO. + £EM 1 H 13-24(REV.10!83) /p F