86-1220 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 456-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED w (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 8ules and Regulatlons of the San-Joaquin Local Health District. Ca Job Address �� a City Loi Size G PM 7 F Owner's Name '`' Address Phone f� G Contractor's Name hq License No. sic)5 7 Z Phone *A:� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ +� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. _ PROP. LINES `°• FOUNDATION AGRICULTURE WELL OTHER�WELL .� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom': ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 1 ❑ Tracy Type of Casing Specifications ❑ Public 0 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by -- Repair Work Done ❑ Type of Pump f ' H.P. State Work Done 9� Wel! Destruction ElWell Diameter Sealing Material (top 50') ` Depth r Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑-(No septic system permitted if public sewer is * ravailable within.200 feet,) Installation will serve: Resid nce_ Commercial ther : Number of living units. Number o bedrooms o, v ®+ Character of soil to,a depth of 3 feet: _ 4a# C 2 Water table depth SEPTIC TANK s ❑ Type/Mfg 'Capacity �,No. Compartments PKG. TREATMENTrPLT'❑ ,` Method of Disposal' Distance to nearest: Well Foundation Property Line f ` i ��// LEACHING LINE I .2e'No. & Length of line 2`` f J f Tota! len `gth/size_.. 0 ! FILTER BED I,El Distance to nearest: Well �� Foundation 1�f Property Line r�0 yr -� t oo I r «. t I ! SEEPAGE PITS 1M/ Depth t Size.- (6f umber SUMPS ❑ Distance to nearest: Well C .{..._ Foundation _ Property Line. p f DISPOSAL PONDS ❑I I.� ;�4-/ 5 v r *- I hereby certify that I have prered this application and"that the work Will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations-of the'SanpaJoaquin 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 h Iring 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 m t call fo a r uired inspections:Complete drawing on reverse side. } Signed �•� [! 1L L-. Title: __ ...._ V. fMIENT USE ONLY � �d FOR DEPAT 7 � pr Application Accepted by.. Date t Area Pit or Grout Inspection by f " Date Final Inspection.by Date Additional Comments: ❑ Stk 466-6781 Lodi 3W3621 ❑ Manteca 87.33 7104 ❑ Tracy 8355-6385 Applicant- Return all copie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk.;CA 95201' FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE" PERMIT'N0. INFO p- +EH 13-24(REV.10/83) c ��'s` EH 14-28 Q Q