87-486 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Ryles and Regulations of the San Joaquin Local Health District. _ Job Address 0 G 0,-, '✓�1�-l�l�.i�_.� CitA4,�of Size PM Owner's Name J �'-'�'Y�� r daressf�3D al. . 6 - Phone 6-f-66 0 Contractor Y:J Address 4.3 P "(License No. A�g X3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ y SYSTEM REPAIR PO' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 111 5i"Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Dept ❑ Eastern Su ace Seal Inst9lled by •4� Repair Work Done p--.-Type-of-Pump "H.P,'� __ ._�..� S_ .. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth _ Filler Material (Below 50') 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. ❑ , Method of Disposal > r Distanc6 to nearest;_;"Well E _ Foundation--.__ _.__ Property Line . , s LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. r 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 employpersons subject to workman's compensa- tion laws of California." f' The applicant u all for all req ired )nspectionS. mplete drawing on reverse side. Signed Date- /-A FOR DEPARTMENT USE ONLY �} i Application Accepted by Date v� Area Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: Q Stk 466-6781 Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 83541385 Applicant- Return all c pies 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 PERMIT NO. +EH13241REV.+/d5J ` �d EH 1128 IR7