85-749 - Laserfiche WebLink

Home Browse Search

4. r APPLICATION FOR PERMIT SAN JOAOUiN LOCAL= HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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 Rules and Regulations of the San Joaquin Local Health District. i,Y' IW'Y �, ,, r _ e - -1 .....-:w4 ,r.. . f , Job Address / 4 �• -� �' ' r 'City' "' 'D 'Lot Size !L2-�e PM Owner's Name Address - //Phone Contract r Address ��. tpLicense NoJ0a � `�' Phone �� 'TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing j ❑ 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 i Well Destruction ❑ Well Diameter Sealing Material (top 501 _ �✓ E Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other f Number of living units: Number of Pedroc Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity C� No. Compartments {4 PKG;TREATMENT PLT. ❑ Method of Disposal C Distance to nearest: Well Foundation Property Line ] _ — ' LEACHING LINE No. & Length of lines ( __ Total length/sU7 FILTER BED: ❑ Distance to nearest: well Foundation /Q Property Line.-._,_ yr SEEPAGE PITS ❑ Depth Size t` * Number SUM�S� I El Distance to nearest: Well Foundation Property Line .DISPOSAL PONDS ❑ 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 lif d regulations-of-the-San Joaquin Local Health District.- ' -'r- Home owner or licensed agent's signature certifies the following: "I certify that in the`performance of,the4ork for which this permit is issued, I shall not employ,any person in such manner as to become subject to workman's compensation faws-of-California.",Contractor's hiring or sub-contracting signature certifies the following:_.1-certify.that.in-the performance-of-the work for•which this'permit is-issued-,l shall employ-persons-subjecf to workman's compensa- tion laws of California." .The applicant must call for a wired inspections. Complete drawing on reverse side. Signed Title: " Date: UIYl + t F9R DEPARTMENT U ONLY i d Application Accepted by5;4Date 6 5 Area I�J Pit or Grout Inspection by Date Final Inspection by ate 7-2`ae Additional Comments: ep ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE I ' INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH 4324(REV.1/851 EH 14-26 r• __ � i