85-624 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN J'OAO.UIN'LOCAL HEALTH DISTRICT 1601 E.�HAZELTON AVE., STOCKTON, CA RECEIVE® JUN - 7195 {Telephone{209) 466=fi781 PERMIT EXPIRES-1�YEAR`FROM DATE ,ISSUED° {Complete'+n Tnpl166t6) ~ 'jt; ` €`I '�?sS'Sft -�- i i 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 Cou;ty Ordinance No.549 for sewage or,,N/o. 1$62 for wel l pump and the Ryles and Regulations of the San Joaquin Oc Local Health District. N/s, ,�U odI t' ,1 i 1 2 t � Lot Size City Job Address a r0 y ;{.. _a tY ... .st .) t,r .-Owner's Name •Tom-�' s'" Address• r tt E p �P40 Address I., License No#Z-1�??C� Phone ContractoS� ' RUCTION NE TYPE OF WELL/PUMP' NEW WELL ❑ WELL REPLACEMENT ❑ F !' SYViM' REPAIR L3. OTHER ❑ PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE - { SEWER LINES,_.. a� � DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS �� FOUNDATI---; A RICULTURE WELLY OTHER WELL PROBLEM A CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL P ' Dia Fof Well Casing El Bottom ❑ Manteca Dia. of Well Excavation , ❑ Industrial p j 'Specifications ❑ Trac Type of Casing ❑ Domestic/Private L1 Gravel Pack ❑ Delta Depth of Grout Seal { Type of Grout j ❑ Public ❑ Other ! �Approx. Depth ❑ Eastern Surface Seal Installed by 1. �ry ❑ Irrigation State Work Done I Repair Work Done E3Type of Pump H.P, Sealing Material /top 50'1'., _ Well Destruction ❑ Well Diameter s Depth Filler Material{Below 50') _ - ----- -- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO a availabl6.With ne200t feetjed-if public sewer is r y�. r Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Water table depth. Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: We �� ll Foundation } - - Total length/size - LEACHING LINE 1:1 No. & Length of lines Property Line ' FILTER BED L3 Distance to nearest: Well Foundation. Size " _ Number I SEEPAGE PITS ❑ Depth Property Line - ❑ . Distance to nearest: Well Foundation 4 SUMPS ;w,, :...•.R, '. .._ + 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. performance of the work for which this permit is issued, Home owner or licensed agent's signature certifies the following: "I certify that in the, I shall not n's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject to workma k certifies the following:"'I cera that in the performance of the work'for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws ifornia." The applic nt m st call for required inspections. Complete drawing on reverse side. I ,�_ b Title: Date: Signed FOR DEPARTM T USE ONLY ' Date 'Area ' l Application Accepted by -4' 1 } Date -7 . ' Final Inspection by Pit or Grout Inspection by Date Additional Comments: i .. racy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369 3G21 ❑ Manteca 823 7104 Applicant- Return all copies to:'Enviroiimental Health Permit/Services 1601 Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE' AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE. PERMWNO. INFO . + EH 13-24(REV.1/s 5) 4� `_�. •.�8 a8' -Cyc-• - �/,w!_ ..._. .._.r_ .5�b� - EH 14-28 , ... .. •._,_ �. - -,,.. .�. . . ..tee . __.__- >. -_ _ -------------