86-72 - Laserfiche WebLink

Home Browse Search

II Ii APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ! 1601 E. HA T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'-FROM DATE ISSUED ,� (Complete in Triplicate) z:. rte. ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, This appl!cation 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. :; ,;�., i,, . I Job Address City 5rf?ca�rat/Lot Size .2-4a X L]f QPM Owner's Name „ w S Address 4ill �&/. ,fir/ Phone Contractor,FL,d yD ;::7 ,LcJ4e� Address i% 4 "�,�_"'// �-- ` �!�"�'4 � �y�^'License No.�ys�]-7 6 ` TYPE OF WELL/PUMP: �I NEW WELL ❑i Phone .535'] WELL REPLACEMENT ❑ DESTRUCTION ❑ r—•---ter PUMP INSTALLATION ❑ � DISTANCE-TO-NEAREST:-SEPTICSYSTEM REPAIR Ll TANK i OTHER E3SEWER LINES � DISPOSAL FLD. PROP. t FOUNDATION 'LINEAGRICULTURE WELL » -- INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - - ---., ❑ Open,Bottom ❑ Manteca Dla. of Well Excavation O Domestic/Private _❑ Gravel PaclK ❑ Tracy T Dia, of Well Casing r❑ Public —.,n -- 1e Type of Casing " ❑ Other ❑ Delta Specifications ` ❑ Irrigation #,.,� Depth of Grout Seal Type of Grout V ' —. pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Q Type of Pump t H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') c s.- Depth Filler Material (Belo 50') r TYPE OF SEPTICwWORK: NEW INSTALLATION ❑ REPAIR/ADDITION J D DESTRUCTION ❑ {Na septic system permitEed!f public sewer is 1 Installation will server; Residence'�Commercialy� available within 200 feet.) } I s-T Other�� ! Number of living units _ Number of bedrooms Y c Character of soil to a:de r` _ Pthof 3 feet: - ! SEPTIC TANK �p.'�'Type/Mfg Water table depth t PKG.TREATMENT-PLT. ❑ 'Capacity No. Compartments' � ..+ i�... - Dista cn a to,nearest: -Well Method of Disposal T �1c Foundation 6 v • � f • !i; ��-� > Property Line �} LEACH ING-LINEw - ., l A #r;. �Nli:'&;Length;of'fines. FILTER BFbZ1�� Total length/size �X Z ❑� Distance to nearest: Well aSd' Foundation as , z Property Line r� SEEPAGE PITS c [B--Depth— !Size' ` c to •r � SUMPS i ❑ Distance to nearest: Well Number fl �^ Qc'� Foundati 1p� Property Line_.c�__ � DISPOSAL PONDS Cl I� � � `'"^ ', !� I hereby certify that 1 have prepared this application and that the-work will b one in accordance with San Joaquin county ordinances, state laws, and I' rules and regulations of the Sah`Joaquin Local Health District., k ' 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 f0ll0wings"1"Certify that Ili Performance of the work for which this permit is issued, I shall employ tion laws of California." I1 p y persons subject to workman's compensa- 4 ; " The applicant must call for all required inspections. Complete drawing on reverse side. k i t Signed I 4 Title: Date: —LJ k ` FOR DEPARTMENT USE ONLY �--Ap`plicetion Acceib - j-� } n �J Date "'6�:/ 4rea" Pit or Grout Inspection byDate� 1U Final Inspection by Date y Additional Comments: II O%tk-.46fr6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Heal Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 !i FEE AMOUNT DUE AMOUNT REMITTED CK 4 INFO CASH RECEIVED BY .DATE PE All t + l 13-24{REV.i/a5) �.Q V EH W28 .. Y .