86-1451 - Laserfiche WebLink

Home Browse Search

s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE-, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATEISSUED (Complete in Triplicate) Application is hereby malicatiOn is de to the San Joaquin No.DistrictHealth 549 for sewage or't to No 1962 for construct install nd the Rules and herein Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance Local Health District. j 13 City Lot Size PM - Job Address �- 5 �".X-r MINI f,A/f �f�pU3E Phone + Owner's Name MA = Address All _ 7/1 Ids/�+ J Phone Q Address�c.r -i L . 'cense No. Contractor WELL REF�LACEMENT ❑ DESTRUCTION LI TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR� -�SfWER CINES :- — Z'SPOSA FLD. PROP. LINE DISTANCE TO NEAREST:-SEPTIC AGRICULTURE L"CURE W LL's �T R WELL PITS/SUMPS FOUNDATION _—�— TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE ----.Y--- -- — Dia. of Well Casing ❑ Open"Sotto'-`m ❑ Manteca Dia. of Weil Excavation �7lndustrial ❑ Tracy Type of Casing Sipecificatioits i ❑ Domestic/Private ❑ Gravel Pack Type of Grout ❑ Other ❑ Delta Depth of Grout Seal 1 ❑ Public Surface Seal Installed by 6 El Irrigation �pprox• Depth ❑ Eastern State Work Done pFA1,S7f DgF�GT1l Repair Work Done ❑ Type of Pump SU H.P. O Well Destruction F1 Well Diameter �— Sealing Material (top 50') i Df' I Depth Filler Material (Below 50'1 rinitted if public sewer is available within 200 feet.) ' TYPE OF SEPTIC WORK: NEW INSTALLATION D. REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system pe i Installation wiN serve: Residence— Co mercigi—Oiher t �� . } Number of living units: Number of bedrobr s � Water table deptA Character of soil to a depth of 3 feet: "> Capacity N9• Compartments I SEPTIC TANK ❑ Type/Mfg t t Method of Disposal i PKG. TREATMENT PLT. El Property Line LL Found$tion'k_ PPirty ty ( / . ` Distance to nearest: Well _ 1 Q LEACHING LINE ❑ No. & Length of�ines Foundation ,-Property Line FILTER BED ❑ Distance to nearest: Well ` Siza' ""� . v Number i SEEPAGE PITS`�' ` ❑'' Depth Property Line ' SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an I rules and reguietions of the San Joaquin Local Health District. work for g this lit is issued, I l not Home owner or licensed agent's signature certifies the following: {certify that ration I wsoof California."Contractor's fl;+nng or sulb-cont act ng gnlature ` employ any person in such manner as to become subject to workman's which thisarsons,subject t workman's compensa 1 certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ p j tion laws of California." Wit f 'all re " d inspections. Complete drawing on r arse ide. r— 8 The applicant .�; a"te: 11,611 Title: Signed �v �iC`"i•-S.� 1 Pte'r I FOR DEPARTMENT USE ONLY i ^� Date ^Datie Application Accepted y Date Final Inspection by Pit or Grout Inspection by { * } ,0 Additional Comments: ." t ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935 638x` "' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5 :^ 95201 I �- CK RECEIVED BY DATE PERMIT'NO. r FEE AMOUNT DUE AMOUNT REMITTED CASH INFO �- + EH 13-24 iREV. EH 14-26