86-492 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. Job Address L City 5iV-0 bKJLot Size PM toS I�C.G'(A.0 f �Mu IL 4)1 1) 'P��1�G � . .. > OwnE:r's Name Address {� GG Phone Contractor Cl i fti Address bL F. elLicense No- Pho1e Z- G TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR rC OTHER ❑ t 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 ❑ Industria! LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Easing ❑ Domestic/Private 17 Gravel Pack ❑ Tracy Type of Casing Specification ❑ Public El Other E) Delta - __Deph o tf Grout Sea! "'� Type of Grout ❑ Irrigation ---Approx. Depth Eastern urf ce Seal Installed by �.i w� Repair Work Done ❑ Type of Pump H.P. . State Work DCone Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 ,] TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L7r-DESTRUCTION ❑ (trio septic system permitted if public sewer is a available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 1 t I Number of living units: Number of bedrooms a Character of soil to a depth of 3 feet: Waterkt ba Ig ent'h SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foutidati6n `*" -- Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line E DISPOSAL PONDS ❑ 3 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 andre ions of the San Joaquin Local Health District. Home own- or ensed 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 ers in such ner as to bec a subject to workman's compensation laws of California." Contractors hiring or sutr contractind'` ignature Certifies the Ilp ing: "I cert tin th rmanc of;he work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of rnia." ; The appG cal a r d i s o s. C plate drawing o averse si Signed X Title: Date: FOR D ARTMENT USE ONLY Application Accepted by Date ��/�—�� Area SY"Gr2itiY"iflspectidn by pate " Final Inspection byy 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.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT-NO + EH 13-24[HEV.I/x 5) s EH 1428