86-449 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTI7 DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Rules and Regulations of the San Joaquin Local Health District. _ _ A�} Job Address ! -I �•��'r'• ►�!o"f -CJi'— n,� ��. City ref Lot Size 9v U^'&u,_o PM Owner's Name Address ' Phone :3 S 4414 Contractgf� icn-t,. �r Address b License No.3_9 �2,moo Phone IP TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , DISPOSAL FLD. PROP. LINE FOUNDATION T AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. ❑ Industrial ❑ Open Bottom C.Manteca Dia. of Well Excavation Die. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of_G rout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is (S'l available withirL200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Numberof Brooms 1 , Character of soil to a depth of 3 feet: /�� L Water table depth SEPTIC TANK Type/Mfg /.(Viet°. h�]= Capacity-, [2!i No. Compartments } PKG. TREATMENT PLT. ❑ �. Method of Disposal G Distance to nearest: Well—5_0 Foundation 10 Property Line __ a 6. 61 LEACHING LINE No. & Length.of lines c IK Total length/size Q Y c r � FILTER BED ❑ Distance to nearest: Well__57�__ Foundation i Q Property Line .S� jF SEEPAGE PITS ❑ Depth Size fQ X,g Number oZ SUMPS 10' Distance to nearest. Well107� Foundation 10' Property Line L DISPOSAL PONDS ❑ - 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."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 st call for aill re uired inspections. Complete drawing on reverse side. '�'}}tt �} C Signed X �� Title: �� Date: g FORD PARTMENT USE ONLY �� Application Accepted by Date�` 2_ Area r Pit Grout Inspection byr.fi:/1� Date Final Inspection try ate -J_��6 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. + EH 1324 IREV.1/8 e —7� EH t4-28