85-1257 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT G SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA N Telephone (209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 't (Complete in Triplicate) z 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.z , Job Address 1130 !. �Gt<l/�� V�fi y" _ -_ City Lot Sitedo PM Owner's Name e�C/.r YA i11?�R/1.0 Address ln� D wr --�-• 'Phone " Contractaf ZLicense No 017(l.Phone ( Q TYPE OF WELL/PUMP: NEW WELL ❑ WELUREPLACEMENT ❑ 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 T Dia. of Well Casing ❑ Domestic/Private- ©"Grave(Pack "O Tracy Y--"""'Type of Cas ng-"— Specifications- 11 Public , ❑ Other ❑ Delta Depth of Grout Seal Type of Grout D Irrigation �Approx..flepth`_ -0 Easternr Surface Seal Installed by Repair Work Done ❑Type of Pump °�,t H.P. t` State Work Done Well Destruction ❑ Well DiameterSealing Material (top_ _ _ �- 50') #Depth—--"-fit Material {Below 501 TYPE OF SEPTIC WORK:. NEW INST-ALLATION•O' REPA ADDITION UEr DESTRUCTION ❑ (No septic system permitted if public sewer is �" available within 200 feet.) Installation will serve: Residence/"+Commercial_ Othert Number of living units: Number of drooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑-...,.Type/•Mfg-- Capacity No. Compartments, A PKG. TREATMENT PL'"T:❑ "' ` , - �-- -----► ~°,v Method of Disposal C� Distance to nearest: ». Well Foundation Property Line LEACHING LINE lirNo. & Length of lines Total length/size FILTER BED_- ❑ Distance to nearest: Well 1-�--._Foundation 10 Property Line SEEPAGE PITS ❑ Depth /S" Size t X• =-'",_ Number SUMPS IJ' Distance to nearest: Well �'n Foundation 10 Property Line—577 DISPOSAL PONDS ❑ h 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. '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."Contractors 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 applicant must call for all re ed inspections. Complete drawing on reverse ' Sr"ned V Title: Date: r FOR DEPAiT ENT USE ONLY F' Application Accepted by Date 15 Area Pit"or Grout Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 -❑ Tracy 835-6M _ Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT NO." INFO CASH + EH"13-24(REV.1/ 185l 5 • 0 0 `V��r } EH(14-26 "