86-1199 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-8781 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. Job Address p �-'+ ro -?E /1 T 1 4-4 6/�!/E:t w' - City Lot Size 1 PM Owner's Name Ys`7x A-�,, et7.9!4, Address Phone 7 Contractor's Name ~ C -/�9 License No. Phone TYPE OF WELL/PUMP: r NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION t `-SYSTEMo` EPAiR ❑ OTHER El / t DISTANCE TO NEAREST: SEPTIC TANK ` k SEWER LINES t DISPOSAL FLDIPROP. LINE `16 n FOUNDATION i--!' AGRICULTURE WELL/(�?� OTHER WELLiC&—�� PITS/SUMPS /Cp'"fi' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '�. [I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exca.�v-a�tion Dia. of Well Casin {� Domestic/Private „XGravel Pack ❑ Tracy Type of Casing/PVV Specifications F. 'S fir`+ 1- ❑ Public / ❑ O her [IDelta Depth of Grout Seal Type of Grout - ) .? ❑ Irrigation 174;Z pprox, Depth ❑ Eastern Surface Seal Installed by -3c. Ca Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material (Below 501 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 Number of living units: Number of bedrooms . t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK .C1 Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT.;❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LiNE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation '1 ' Property Line SEEPAGE PITS ❑ Depth Size Number--.. SUMPS ❑ Distance to nearest: Well Foundatiot % Property Line"-1 i DISPOSAL PONDS ❑ ' 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.� J , Home owner or licensed agent's signature certifies the follpwing: "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 hieing-or sub-contracting signpure certifies the following:"I certify that in the performance of the work-for-which this permit is issued,f shall employ p4morls subject to workman s compensa- tion laws of California." , The applicant `st call for ail 2red inspections. Complete drawing on reverse side. ...__.Si ned- `g - . . – Title:" Cllz`'3 Date: _�.".�.;� FOR DEPARTMENT USE ONLY n Application Accepted by Date 9-/zw—d�wArea CJ Pi rGro t In ction by Date Final Inspection by Date JLIY .Additional Comments: If Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 App icant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �P;ERMIT NO. + EH 1426 EH 1324(REV.10183) i