85-1563 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN4LOCACHEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 112091 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED { 01 Y; (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. Job Address -3pr ` x'� City Lot Size / PM ,+X Owner's Name _ F` �J�s � Address Phone Contractor 0;Lg Ad El. 0 MT�4- License No. � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑.Manteca Dia. of Well Excavation Dia. of Well Casing �� :'• ' {] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications. ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout' ❑ 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 501 A Depth Filler Material {Below,501 w TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) a Installation will serve: Residence fft--Commercial nOther Number of living units: t Number of bedrooms t Character,of soil to a depth of�3 feet: DO 67 —Water table depth SEPTIC TANK ❑ Type/Mfg Q —` 'Capacity.A- ' No. Compartments PKG. TREATMENT PLT. ❑ I � Method of Disposal 4 Distance to nearest: Well Foundation-rte�— Property Line r$s 1 LEACHING LINE c No. & Length of lines Total Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 2 Property Line SEEPAGE PITS ❑ Depth Size — Number SUMPS ❑ Distance to nearest: Well .Foounda#ion Property.Line DISPOSAL PONDS ❑ 6 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. " 1: . Home owner or licensed agent's signature certifies the following: "I certif}i•,Q-Qin the performance of the work for which this permit is issued, I shall not employ ariy 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." k The.applicant must call fo all requ'ed inspections. Complete drawing on reverse side; �f i Signed X Title:= Date: l OR DEPARTMENT USE ONLY +� ¢ } .-s Application Accepted by Date ` P)f-,6r.Grout Inspection.by Date Final Inspection by Date Additional Comments: k ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Seryices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 max — -FEE .,,. .A_MOUNT DUE — AMOUNT REMITTED GASH—w= — RECEIVED BY_„�_ OATS- PRMI7 -INFO, -- 1�n— _ ._ ..... f ..+ EFI13-241flEV.i/ssl 4�-a0 .- - '•':,�, W?> ✓:.J.i...1. An