85-763 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT g SAN JOAQUlN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AYE., STOCKTON, CA Telephone (209) 466-676f PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED ' ` (Complete in Triplicate) jj, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describl ( y made in compliance with San Joaquin County Ordinance No.549 for sewage or No. T862 for well/ um ry Local Health District. ; ed. This application is p p and the Rules and Regulations of the San Joaquin Job Address City {Lot Size Owner's Name r. .. t :. I' QPM 1 ".Address �� _ ,,w p � }• � Phon on lS�/l ! 3 � Ctractor4r ►1y G} e _ Q� ;° ress TYPE OF WELL/PUMP: License No. NEW WELL r Phone WELL REPLACEMENT F1 PUMP INSTALLATION ElDESTRUCTION ❑ i V DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR E] OTHER F-16 ; r - —� SEWER LINES FOUNDATION �- DISPOSAL FLD. PROP. LINE --� AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIOPITS/SUMP$ El Industrial ❑ Open Bottom -- x Domestic/Private ❑ Manteca NS Dia. of Well Excavation r ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ ❑ Public Other Type of Casing ��c, I� ��l Delta Depth of Grout Seal ! Specifications Q Irrigation 4z.LA 'PDepth ❑ stern Surface Seal Installed by Type of Grout � Repair Work Done ❑ iTYPe:.of Pump --{1r�w♦� s� Ea p H.P.Well Destruction ❑ 'Well Diameter State Work Done IM i i Sealing Material (top 50') Depth Filler Material (Below 5(y) 0 1 lot TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION EJ .4 ❑ {No septic system permitted if I� Installation will serve: Residence available within 200 feet.) Public sewer is Commercial, Other Number of living units: "' Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ` I 1 # ❑ Type/Mfg E Water table,depth f PKG. TREATMENT PLT. p -- Capacity ii fN Compartments �� # Distance to nearest: Well � Method;of'Disposal �� Foundation I" property 11 ine rte. LEACHING LINE11 t y r No. & Length of lines s FILTER BED L7 Di iari�e?to nearest: Well Total length/size i i; �� Foundation Property Line+.� #} SEEPAGE PITS _I I- SUMPS Q Depth 'Size s Distance to nearest: Well Number »+- DISPOSAL PONDS p"__ f� " �-- Foundation Property Line- rules hereby certify that I have.prepared this application and that the work will be done in accordance with San Joaquin' un ordinances" rules and regulations of the San Joaquin Local Health that Home owner or licensed agent's signature certifies the followin ystate Is an an employ any person in such manner'as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signat e g: "I certify that in the performance of the work for which this permit is issP ued, !sliail n•t certifies the following:"f certify thai in the performance of the work for which this permit is issued, I xshall employ tion laws of California." I' p y persons subject to workman's compen a- The applicant must call for all required inspections. Complete drawing on reverse side. IJ ; Signed ) Title: d �illl l2h L h� h��r' °t, Date: F D P TMENT USE ONr✓Y f1 ,Alll ppp Application Accepted `' .Date- - A�ea`w`w Pit ar.Grout..fnspe b - 'Final Inspection-b Additional Comm n �Date�� ❑ Stk 466.8781 ❑ Lodi 369-3621 ❑ Ma sea '823- 104 ❑ Tracy 5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., Box 2009, Stk., CA 901 ' !� P.O: i r , FEE AMOUNT AMOUNT DUE INFO NT REMITTEp C_ " RECEIVED BY DATE + EH 1324 rREV.t/s 51 •� '""'- ----^- PERMIT"NO.'�M EH 14-26 'I� •. _�. _ --" _ .-