85-503 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT r- MT7 SAN JOAQUIN"�OCACHEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'1'YEA'R'FROM'-DATE ISSUED (Complete in Triplicate) .'+ ` "' ?`rt` ="o'•"f:'-.:-',�f'';,' �+ .s��. r- ?„ ar r. :. I t��°.> rx�r"y3:i! .EG' ill.#Ar..w Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.,THs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Arles and Regulations of the San.Joaquin 'Local Health District. ...^k <. 3 10 t;l"'�SON" Job Address la��v �l, r Ir�� e N; r1k.7 i io- ' ,Lot Size �b `'� ' PM' L`' yfTfIi00t,- i :7[i - Owner's Nama. SCh C 1 Address �a �' [ af�i�N._ , !TA Phone` 1-�!'7 Contractor CL Y/01 Address it ,S i' License No..3._6g/Ja3 Phone TYPE OF WELL/PUMP: NEW WELL.K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR..E OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK -Lir) 1 SEWER LINES DISPOSAL FLD. PROP. LINE S-20 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! �� ❑ Industrial ' `Open Bottom ❑ Manteca Dia. of Well Excavat1io�n fU �d Dia. of Well Casing ZO XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing � � Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Sealy Type-of Grout, -.❑ Irrigation ---Approx. Depth ❑ Ea`erns- 1 Surface Seal Installed by —tet I Repair Work Done ❑ Type of Pump P.-�7 /V�6Tyf.�p State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50')- Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other I Number of living.units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ ��- I PKG. TREATMENT PLT. ❑ Method of Disposal C` I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 70 FILTER BED ❑ Distance to nearest: Well Foundation Property Line k SEEPAGE PITS ❑ Depth " Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line.— DISPOSAL ine.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. 4 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work 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 of California." , The applica ust c I fo7z, ee uired inspections. Complete drawing on reverse side. ~1.I p Signed - Title: &✓-77 Date: '7/r2 a?/Q �� " FOR 12EPARTMENT USE ONLY Application Accepted-by * rY Date " Area Pit or Grout Inspection by Date Final Inspection byDate Additional Comments: g' ' "❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑+Tracy 835-6385 Applicant- Return all copies to:'Environmental'Health Permit/5eivices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l )FEE NFO .AMOUNT_ .DUE AMOUNT REMITTED. CASH RECEIVED BY .� DATE PERMIT"N0. + EH 73-24[REV.t/a5) - - �S EH 13-26 ` (J .7✓00h I