87-796 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ^ SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,:STOCKTON, CA �1?►vw Wim, Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED. f, (Complete in Triplicate), U Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereinldescribed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address -AJ , City Lot Size PM k Owner's Name &AAR �- _ Address-- _/U, ,S I rPhone ` r 0 �S �p F Contractor ise Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL — PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA'�CONSTRUCTION SPECIFICATIONS l ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done ❑ T 1 ype of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: 1 Number of bedrooms it Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth Type/Mfg Capacity o No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line s ' LEACHING LINE ❑, No. & Length of lines Total length/size k FILTER BED ❑ Distance to nearest:+l —Weil 4 Foundation-- —n— Property`L7ne j SEEPAGE PITS ❑ Depth Size R Number SUMPS 01,,Distance.to nearest: . Well Foundation Property Line DISPOSAL PONDS 0`1 14 I 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 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 perforritance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t call for all r quired in ctions. Complete drawing on reverse side. 4 Signed X Title: Date: 3_ k g— Q1 FOR DEPARTMENT USE ONLY Application Accepted by 4 Date '21O� Area Pit or Grout Inspection b Y DateFinal Inspection Date�� �� ( ou 3 e c c+ Additional Comments: G.Y` GcYc,J l,c.,p, 11Stk 466-6781 IDLath 369-3621 ❑ Manteca 7104 12 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services. 1601 E. Hazelton Ave., P.O. Box!.3 9, Stk., CA 1 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. C �SH + EH 14-24 1 R EV.i i n 51 / .rJ/ - EH 14 26 LVA /- _