85-1489 - 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) 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 Jo quip Local Health District. Job Address T 1174.57 rielia R-d- City TrAely Lot Size lkcrlia e PM Owner's NameL�rj-j7_51111 j imn ..'Address S 2 rn P. Phone Well to be drilled D� Hennimg Bros Contractor's Name License No. Phone 83 ''"2787 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ l 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 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ; Dia. of Well Casing V I 41 Domestic/Private JKI Gravel Pack JJ Tracy 4 Type.of Casing. "EVC Aea Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout -J ❑ Irrigation ---Approx. Depth C1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Y Well Destruction 11 Well Diameter Sealing Material (top 50'1 i Depth :Filler Material (Below501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O DESTRUCTION ❑ (No septic system permitted if public sewer is 4-- available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r " Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ? FILTER BED ❑ Distance to nearest: Well ;'Foundation, Property Line -—�. _ _�... � ' SEEPAGE PITS ❑ Depth SizeNumber SUMPS El Distance to nearest: Well �` Foundation Property Line I DISPOSAL--PONDS-- El. hereby certify that I have prepared this application and that the work will be done in accordance with San Jo`agliin 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 California." The applicant st call for all quire in ctio S. o eta drawing on reverse side- " E Signed Title:(oyc rn - .nr. Date: 2 �� FOR DEPARTMENT USE ONLY Application Accepted by � '�.� Date /�� Area e Pit or Grout Inspection by Date/ Final Inspection by �_fat 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 AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT"NO. ` INFO CASH 1 + EHs13-24{REV.'lO1Si{ 0� �5 4 Li - •'A1 eC _ fD EH 1426 V 7