85-949 - Laserfiche WebLink

Home Browse Search

APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKT_ON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T_ (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 Rules and Regulations of the San Joaquin Local Health District. f r L� c . Job Address � 3 3 d 3 �` -" City� r Lot Size PM � 1 s.t 3.�G n r Phone Owner's Name _ Addres �j Contractor's Name cense No. Phone�� v U TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 2- OTHER ❑ v 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 Er"Domestic/Private ❑ Gravel Pack ❑ Tracy r Type of Casing Specifications ❑ Public ❑ Other ❑ Delta I 'Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. De th ❑ Eastern tSu ace Seal Installed by Repair Work Done Q Type of Pump"_ H.P.i State Work Done LU Well Destruction ❑ Well Diameter Sealing' Material- 507-50'ul \F, UJ Depth Filler•Material (Below"50.) r, TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ -REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �J I--- --' -- = - available within 200 feet.i U Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg a Capacity No. Compartments { PKG. TREATMENT PLT. ❑ Method of Disposal r r *•.3 - -:-- --_--»�---•--- -------Distance,to-nearest:-�Well�-- -•-----FoundationProperty Line---^--- VVV LEACHING LINE ❑ No. & Length of lines Total length/size C FILTER BED ❑ Distance to nearest:.: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number $ SUMPS ❑ Distance to nearest:- Well Foundation Property Line DISPOSAL PONDS ❑ t 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." 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 Californ' J The applicant rn I fo all re nspections. mpletewing o verse side. Signed Title: Datel rs FOR D PARTMENT USE ONLY r Application Accepted by Date r.- Area / Z Pit or Grout Inspection by Date Final Inspection by /�/ Date 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 l r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`N0, INFO ( CASH + EH13-24IREV.10163h LS EH 1428 1 T i P