86-79 - Laserfiche WebLink

Home Browse Search

t 4 - 2 APPLICATION FOR PERMIT F: SAN JOAQUIN LOCAL HEALTH DISTRICT t 1501 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-5781 PERMIT EXPIRES if YEAR FROM DATE ISSUED. 3;�41l,esi i.r,,(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%fes and.Regulations of the San Joaquin Local Health District. Oi -�1 w. J 6 Address _ City� ,Lot Size MPM- Owner's Name - ► Address _ Phone Cont'ractor's Name _ License No. at _aLm. Phone e TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMEN71 DESTRUCTION PUMP INSTALLATION . SYSTEM REPAIR ❑ OTHER ❑ m• DISTANCE TI S TO NEAREST: SEPTIC TANK i ... �-�.Sk�1(EFj..I:II�ES _.DISP,OSAL.F1D,1Z-a _,PROP.,�LINf;,�-� FOUNDATIONr�-AGRICULTURE WELL OTHER WELL " PITIT _ �...— S/SUMPS INTENDED USE TYPE OF WELL PROBLEM;AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom - ❑ Manteca Z` Dia. of Well Excavation Dia. of Well Ca ing fP (Domestic/Private It Gravel Pack ❑ THOY 1 tiType of Casing-&'- Specifications `/0 *S A a� ❑ Public ❑ Other �`""-*""❑'pita Depth of Grout Seal —, Type of Grout i X 4 4C ❑ Irrigation &AQ_Approx.iDeptth D Easterp Surface Seal Installed by Repair Work Done ❑ Type of Pump SS/I H.P._ _ State Work Done is ( "IQal Well Destruction Well Diameter - Sealing Material f_p 50'1 S'lEe E /A6t�'.,N eu� Depth # f y Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ •''DESTRUCTION ❑ (No septic system permitted if public sewer is �I R I available within 200 feet.) Installation will serve: Residence'' Commercial+ IOther Number of living units: :Number of bedms t Character of soil to a depth of 3 f ee t: i Water table depth SEPTICj�TANK ❑ Type--/Mf i T"7 . g! i Cap ac!tY No. Compartments PKG. TREATMENT PLT. ❑ I ,ted, Method of Disposal 1 Distance tip isEerest: 1tVe`II--- ---�° Foundation �� Property Line �F I ,.e2 7 LEACHING LINE ❑ No. & Length of lines r '"` ` - ��E� Total length/size FILTER BED ❑ Distance to nearest: Well P, Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number # SUMPSI� ElDistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby 6rtify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state.laws, and -rufes,and-regulations-of-the-San-doaquirr-Local-Health-District.... — Home oJvner or licensed agent's signature certifies the following: "I certifythatin the performance of the work for which this permit is issued, !shall not employ any person in such manner as to become subject to workmaA's,compAlltlon 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 apple ant must call for all Vired inspectio Complete drawing on reverse side. , r Signed Title: : Date: DEPARTMENT NLY r Application Accepted by ` Date Pit or G��ut Inspectio Date Final Inspection by �' Date �p w. 1, Additional Comments: ❑ Stk1.- 781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 —-�— Applicant� Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AM INFO OUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT•`NO... + EH 1324 MIEV.10/831 }} �� ,/ -71 EH-1426