85-1524 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Cf -Z3 (Complete in Triplicate) a Lo-T J 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,p j �} A` �'/� Job Address �a S CSI/�/°��t- /�� City LDN Lot Size t�S' A`-TPM T rG �'T � Address �O � �2 Owner's Name Phonec,�I 7 �i� y f��I �yy �'�i9/II�/7y 3��16�3 Phon ! /s2- Contractor �p/VL�O - /� Address / .v�^� � License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEW REPAIR ❑ OTHER ❑ 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 ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications T ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout v ❑ 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 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is " available within 200 feet.) 60 Installation will serve: Residence x Commercial_ Other �C P�fl Number of-living units: Number of a rooms �GFr } Co Character of soil to a depth of 3 feet: A d � *` Water table depth 3 5 SEPTIC TANK ❑ Type/Mfg� p�CQ�T Capacity �a� No. Compartments PKG. TREATMENT PLT. ❑ � oo�,,� �Z x Method of Disposal Distance to nearest: Well 'Foundation Property Line 00 i LEACHING LINE ❑ . No. & Length of lines L Total length/size FILTER BED ❑ - Distance to nearest: Well Foundation 446 Property Line _v_ Zx 10CL A SEEPAGE PITS ❑ Depth '� SAND Size � �� Number11 _� ' d L¢ ,Pro SUMPS� ,�Distance to nearest: Well� Foundation party Line 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.' I Home owner or licensed agent's signature certifies the following: I certify that in the performance of the wdW 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 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 .f Califor The applica mus cal r all re ired inspect ns. Complete drawing on reverse side. r Signed Title: Date: FOR DEPARTM T USE ONLY Application Accepted by Date_ f��- +► Area �7 Pit or Grout Inspection b00 Date Final Inspection by date - D Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental ea Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Sik., CA 95201 FEE AMOUNT DUESft—AMOUNT REMITTED C1rHRECEIVED BY DATE PERMITNO. INFO Ery laza{qev5 • O o �� " �`l�°��xS FsS-�SZ