85-1268 - Laserfiche WebLink

Home Browse Search

x7- 1! 'I APPLICATION FOR PERMIT SAN JOAQUIN LOCALHEALTH DISTRICT 1601 E. HAZEIRTONAVE., STOCKTON,FCA Telephone (209) 466-6781 PERMIT EXPIRES.1-YEAR`FROM DATE ISSUED (Complete in Triplicate) 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 Ryles and Regulations of the San Joaquin Local Health District. + " ]`�6-,3 o F, Job Address CitytJwC�iwiQ ff' :3 Lot Size 0,PJ A2 PM Owner's Name - Address 4 1 �• F ' r"^� -Phone I o ,i Gontracto Ol —Address- '�' -'-License=lVc:�—ka a Phone �' j�S� TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT 0 'DESTRUCTION ❑ i .--PUMP-INSTALLATION-M-----SYSTEM-REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'C ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing ! 1-1 Domestic/Private ❑ Gravel Pack L1 Tracy TYPe of Casing I Specifications 3 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 4 Type of Grout 3: - ❑ 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 50') Depth filler Materia! (Below 50') W TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI ADDITION la'DESTRUCTION ❑ INo septic system permitted if public sewer is �. available within 200 feet.) Installation will serve: Residence_, Commercial— Other Number of living units: / Number f edrooms 4 Character of soil to a de—ptof 3feet: --r-� Water table depth ! SEPTIC TANK L/h:Ty1 L/Mfg I Capacity �p No. Compartments �- i PKG. TREATMENT PLT. ❑ I I Method of Disposal Distance to nearest: Well Foundation !< C Property Line LEACHING LINE 9KNo. & Length of lines �' Total length/size I FILTER BED ❑ Distance to,nearest: , Well�� Foundation _I!'�' Pr-operty Line SEEPAGE PITS f"�Depth"-' ~ Size 33 Number OR ❑ I4EDistance to nearest: Well}00' Foundation I G'`f t�Property Line S � ; DISPOSAL PONDS r/ I hereby certify that I have prepared this application and that7the work will-be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San-Joaquiri Local Health District Home owner or licensed agent's signature certifies the following: "I ceriify'that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as/io become.subject.to Workman s compensation laws of California Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the perform�ncc of the work foRwhich this permit is issued, I'shall employ persons subject to workman's compensa- tion laws of California." �i � � Za The applicant must call for all;required inspections. Complete drawing on reverse side. ) Signed r Title: V i Y, �! i Date: I C RIFORD Pi4fMNT USE ONLY i �9 f j _. Application Accepted by I`'1 7 '-Date l Area i or Grout Inspection Da e 6" Fina! Inspection by14 Date/�s— + w Additional Comments--, ❑ Stk 466-678v1 -'A_C1 Lodi 369-3621 ❑ Manteca ;823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to:EnvirpnineritaI Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED �CASH RECEIVED BY DATE PERMIT NO INFO ' i + EH13.24(REv.1/a5) 10/ 1 EH 1428