85-632 - Laserfiche WebLink

Home Browse Search

". APPLICATION FOR PERMIT �. i. SAN JOAQUIN`LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1• f _ ' j �. : . , . v ... . (Complete in Triplicate) lh- '-f ulations of the San Joaquin Application is hereby made to the San Joaquin ui Ordinance No.D549 for sewage or INo�1862 for well/pump and the Rules This application is made in compliance with San Joaquin C tY p Local Health District. 50 x 100 I f $tOCRCton Lot Size PM I 852 DeniseiSt. city I ,. Al, r Job Address : 465-441:1 1. P.O. Sox 2027 Stockton, CA Phone Col l i ns-ROSSon lieu• Co• Address owner's Name, 459545 465-4411 p,O. BOX 2021 License 1Vo. Phone Contractor Collins-Rosson Address DESTRUCTION NEW WELL ❑ WELL REPLACEMENT ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER C3PUMP INSTALLATION ElSEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION �- INTENDED USE TYPE-GF_WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing Dia. of Well Excavation ! ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications Type of Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout ❑ Other ❑ Delta Depth of Grout Seal j El Public Surface Seal Installed by k ❑ Irrigation �Approx. Depth ❑ Eastern State Work Done 1 H.P. Repair Work Dane ❑ Type of Pump 7---- Sealing Material Itop 50'1 —COD P Well Destruction Well Diameter - �al � r Depth j �� Filler Material (Below 50'1 f' =available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT10t � =.'.No septic system permitted if public sewer Is Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Water table depth- . �- Character of-soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal I PKG. TREATMENT PLT. ❑ Property Line t Distance to nearest: Well Foundation -- t Total length/size LEACHING LINE ❑ No. & Length of lines Foundation Property Line FILTER BED ❑ Distance to nearest: Well Number SEEPAGE PITS ` ElDepth Size SUMPS _ El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ( . hat the work will be done in accordance with San Joaquin county ordinances, state laws, ad ri I hereby certify that I have prepared this application and t f rules and regulations of the San Joaquin Local Health Districtg k this permit is i Home owner or licensed manner-sias to become subject to workman's compensation l: 11 certify that in the aewsoof California."Contractor's'hiring or sub-contracting l signatushall re employ any person in such which this permit is issued, I shall employ persons subject to workman's compens certifies the following:"I certify that in the performance of the work for ti tion laws of Californian" The applicant-must call f al qu' spec" ns. Complete drawing on reverse side. 6-15_,$5 Title: Partner," Date: Signed FOR DEPARTMENT USE ONLY i. Date Application Accepted by' l Final Inspection by Date Pit or Grout Inspection by Date�� .-Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 • ❑ Stk 466-6781 ❑ Lodi 369 3621 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT N0. FEE AMOUNT DUE AMOUNT REMITTED INFO I +EH13-24(MV. I EH 14.28