86-94 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 Ryles and Regulations of the San Joaquin Local Health District. NIA/ y QQ Job Address /d 3�P Q `V Jul City 4I , Lot Size PM Owner's Name Address _ 3 q 1 r JYq ! Phone 19 ` Q ` 76 - _: 5Z, ZCo Phon Contract Address icense Nox„ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL 'F PROBLEMAREACONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca', ` Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack--, -❑ Tracy Type of Casing k Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation "_A15pfDX. 'Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') uJ Depth Filler Material (Below 50') s TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION El,(No septic system permitted if public sewer is i/ available within 200 feet.) Installation will serve: Residence +!r Commercial— Other Number of living units:--Cl—si�� Number'of bedrooms Character of soil to a depth of 3•feet: w Water table depth SEPTIC TANK R?'-Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ / Method of DiTosal Distance to nearest: Well.-._, Foundation ( -_" Property Line `-.-._-.. LEACHING LINE 10 No. & Length of lines ` i ofal length/size X r FILTER BED ❑ Distance to nearest: +.Well //�l�.. Foundation Property Lirfe SEEPAGE PITS 5r Depth C7 S_ !7�9 361 Number SUMPS ❑ Distance to nearest: Welles Foundation _ Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application Wnr that the work will be db a 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: 1 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." The applicant must call all quired inspections. Complete drawing on rers id VSigned Title: V r Date: T(� �� C] FOR DEPARTMENT USE ONLY / � a Application Accepted by Date r/ Area 74, 91 Pit r Grout Inspection by Date Final Inspection by Date ,S Additional Comments: ❑ Stk 46135-67811 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk.,tA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-24{REV.1/65] , �� 31f $6 �4 �['>ILA EH 14-26 �D _l