85-1385 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781' PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED' (Complete in Triplicate) " kms. . fir: 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.549forwage�roorrrNNnpo. 1862 for well/pump and the R41es and Regulations of the San Joaquin Local Health District. ` /' y { " Jab Addr City C1C'T'na! Lot Size �S�dttr P.SPM Owner's Name 1Z/ - Address" tjSb� t k &,W C.w �� Phorle Contractor Address License No. TYPE OF,WELL/PUMP: 1QEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ "Lt PUMP INSTALLATION SYSTEM REPAIR_❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE De� FOUNDATION AGRICULTURE WELL OTHER WELL /n� PITS/SUMPS Zalp�Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTLON SPECIFICATIONS ❑ Indusirial ❑ Open Bottom ❑ Manteca \'A Dia''of Welis xcavation i?�' _ Dia. of Well Casing r Domestic/Private 7Gravel Pa`ek """�`' ❑,7rac�y Type of CSsIFi pl/L /6 Q -Specifications /6p ❑ Public ❑ Other - L' f7 �elta. Depth of Grout seal pe of Grout i ❑ Irrigation �0—.Approx. Depth ❑ ast e ,Surface Seal Installed by tfY Repair Work Done ❑ Type of Pump H.P.. State Work Dane Well Destruction ❑ Weil Diameter 1--Sealing Material (top 50'1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is +� ! available within 200 feet.) j Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms 4 Ch4racter of soil to a depth of 3 feet: t , Water table depth SEPTICJANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line S LEACHING LINE Irl No" & Length of lines Total length/size FILTER`BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation_ Property Line DISPOSAL PONDS ❑ I hereby[certify that I have prepared-this applicetioA 7ari6 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. _ Home o%iiiier or li ense&agent's-signaturU-Mrtffies t 1F—e"following: "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-sObject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: I cern that in the rfo`rmance`of the work for which this permit is issued, I shall employ g certify 1'e p p y persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. t Signed K— J`—OF- - Title: ��-u �. Data: 1 i FOR DEPARTMENT USE ONLY J t Application Accepted by Date i [ Area Pit or-Grout Inspection by N Date i Final Inspection by Date s Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE P INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED_RECEIVED BY — DATE PERMIVNO. - +EH 13.24(REV..3/;a5 .. - �,. (d� JqVII yW - x I(`flZ— per. 17JgS•� EH 1426