85-1513 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,:STOCKTON, CA Telephone (209) 466-$781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate) r: 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 v rty Lot Size PM Owner's Name Address '.1«• Q Z^' I4 i •" fk Phone p 00 Contactor Address- -,•.,, —� -.x;- -,� , �. w..�.-- -- �. -_ TYPE.OF-WEL-L/PUMP: - License No- Phone f NEW WELL ❑ WELD REPLACEMENT ❑ DESTRUCTION ❑ P PUMP INSTALLATION ❑ 5Y57EM REPAIR F) ! i DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE A FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom a. ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private Dia. of Well Casing i ❑ Gravel Pack' ❑ Tracy Type of Casing ❑ Public C] Other ❑ Delta Specifications I Depth of Grout Seal Type of Grout Ll Irrigation _-_,gpprox..-Depth-_ -❑_ Eastern � OSurface Seal Installed by Repair Work Done ❑ Type of PumpH p `Well Destruction ❑ Well DiameterState Work Done Sealing Material (top 50')- I Depth Filler Material (Below 501) + TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION {No septic system permitted if public sower is i ii Installation will serve: Residence Commercial` Other available within 200 feet.) t Number of living units: Number of bedrooms ? Character of soil to a depth of 31feet: SEPTIC TANK Water table depth (❑,, Type/Mfg Capacity NC PKG. TREATMENT PLT.`{ ' No. r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE * ❑ No}�& Length of lines FILTER BED ' Total length/size ' ❑ Distance to nearest: Well Foundation 4 Property Liner t tr' SEEPAGE PITSC1 '.Depth i � Size ^ k _ Number SUMPS ; '`;' ' 4❑- Distan a to nearest Well Foundafio " Property Line DISPOSAL PONDS ❑ . . I I hereby certify that,1.have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and'.regulatibns of the San Joaquin Local Health District. 'Home owner or licensed agent's signature certifies,the following: "I certify that in the performance of the work for which this employ any person in such manner as to become subject to workman's compensation-laws-of_California."Contractor's hiring ops�bl(contract rlgt is issued, lsignetu�e f 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- tian laws of,Califo'rnia.".� y 1 j The applicant m t call for all required inspections. Complete drawing on reverse side. Signed X .Title: Date: FOR DEPARTMENT USE ONLY A [ r , 1 Application Accepted by V� _ Z 2, r,F Jam Date ` O Area Pit or Grout Inspection by Date Final Inspection by Date �ddrtlonal Comments: - ��St Stk 466-6781 ❑ Lodi 369 3627' ❑ Mante 823-7104 C1 Tracy 56385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. H efton Ave. P.O. Box 2009, 5tk., GA 95201 G io AMDUNT DUE AMOUNT REMITTED C INFO A RECEIVED BY DATE PERMIT NO. 6+ EH 13-24 MEV.I n 5) EH 142s