86-800 - Laserfiche WebLink

Home Browse Search

a �- APPLICATION FOR PERMIT -�----_ rn6 �Y SAN JOAQUIN LOCAL HEALTH DISTRICT �� (DPXi i 1601 E. �HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ; Jf ' PERMIT EXPIRES 'I YEAR FROM DATE ISSUE `�! Jam/ yJ pJvri�` ", (Complete in Triplicate) ,> —Pt)h- ih Application is hereby made to the Sart Joaquin Local Health District for a permit to construct and/or instal the work herein describ . This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump an the Rules and Regulation of the San Joaquin,:�,/ Local Health District. .:4x59Th r` w7k� recrarl'lQ�, 7}'� Job Address ✓ 1 z. r•„k f �1"�d l '�.� C r YY City Lot Size PM //�� f ok Owner's Name _C 0, Address C�onP Rif` 41 Contractor's Name �"' I icense No. a Phoney_3 39—9 1355 TYPE OFWELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA QST SEPTIC TANK moo �S_EWER LINES �'�. �'DI DISPOSAL FLD PROP. LINE 1 ' # FQUNDATION ` AGRICULTURE WELL T� OTHER WELL- PITS/SUfVIPS INTENDED USE �TYPE�OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO X li ndust""tial )kopen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Dom`estic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications • 1�!i xi ❑ Public ❑ Other' O'D'elta —Depth of"Grout Seams �Q.. Type of Grout 4,� ❑ Irrigation ---,Approx. Depth ❑ Eastern Surface Seal Installed by F l Repair Work Done ❑ Type�of Pump I H.P. State Work Done Well-Destruction ❑ Well.-Diameter ... Sealingerial (top 50')5' ,�--- } Depths Filler Material (Below 50')' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is � �`-✓ ( available within 200 feet.) ' Installation will serve: Residence— Commercial_ Other.0 27— ✓r... . ._ �-, • r t Number of living units: - Numbefr of bedrooms Character of soil to a depth of 3 feet: ° a '`--f- Water table depth SEPTIC TANK ❑ Type/Mfg ?f Capacity No. Compartments PKG. TREATMENT PLT. ❑ ; " I Method of Disposal r Distance to nearest: Well ,Foundation Property Line { LEACHING LINE ❑ No. >§ Length of lines � Total lengthlsize � FILTER BED Distance tolnearest: Well Foundation k P o L1perty Line SEEPAGE PITS ❑ Depth i Size I Number SUMPS. _. .-_ 0. Distance to neatest: Well, Foun .x Property Line.. = - ` DISPOSAL PONDS ❑ 1* I hereby cert' that I have prepared this application and that the work will be done in accordance with San Joaquin rfY P p in county ordinances, state laws, and rules and regulations of the San Joaquin`ocal Health District. f 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." Contractors 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 mus for all required inspectComplete drawing on reverse side. Q f Signed Title: T Date: FOR DEPARTMENT USE ONLY r� Application Accepted by 'fry [ Date -7i�7 � Area Pit or out spection by Date `-' Final Inspection by Date Additional Comments: ❑ Stk 466-6781 0 Lodi 369-IUI ❑ 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 FEE INFO AMOUNT DUE 7 AMOUNT REMITTED CCAK 0 RECEIVED BY DATE PERMIT'NO. EH 3-24 y,EH 1428(REV.10!83) ! +�Q r - "/4