85-1068 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT +- SAN JOAQUIN LOCAL HEALTH DISTRICT ~ 1601 E. HAZEL T ON AVE.,iSTOCKTON, 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. Job Address City Lot Size PM Owner's Name rfYl V/,e� � Address �Q Phone tV I � Contract Address t�0 . License 1Vos_2sa�&_Phone' !o -SI/017 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 13 SYSTEM REPAIR i OTHER ID a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 %- - —Diaf of Well Casing r ❑ Domestic/Private C1Gravel Pack ElTracy Type of Casing , '�_ 'y Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout,Seal- '--- - ' Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by t t I Repair Work Done ❑ Type of Pump H.P. ` -` I State Work Donee Well Destruction ❑ Well Diameter Sealing Material Itop 50'I" �' i Depth Filler Material IBelbw 50')- "s TYPE OF SEPTIC WORK: NEW INSTALLATION IK REPAIR/ADDITION ❑, DESTRUCTION ❑ (No septic system permitted if public sewer is 'available within 200 feet.) Q - Q 3 Installation will serve: Residence v/Commercial_�Other i t Number of living units: Number edroo s , Character of soil to a,depth of 3 feet: �i - � t Wate table depth `S SEPTIC TANK 12"'Type/Mfg I Capacity 16450 � No. Compartments-.- PKG. TREATMENT PLT. ❑ ��f� t j �, Method of Disposal Distance to nearest: Well ' Foundation f'10 Property Line S (:r , LEACHING LINE No. & Length of lines �O "-'`. �+ r`otallength ize FILTER BED ❑ Distance to nearest: 'Well ",'Foundation.ID Property Line SEEPAGE PITS V Depth Size .33 '" ' y` Number �" r SUMPS 13Distance to nearest: Well '(00fFoundation Property Line Property `. DISPOSAL PONDS ❑ F- i I hereby certify that i have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. P I V Home owner or licensed agent's signature certifies the following: "I certify that in the performancelof 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,_1 shall'employ persons subject to workman's compensa- tion laws of California." The applicant ust call f II-r wired inspections. Complete drawing on,reverse si a � 4 ` Signed Title: C� Date: AmtU� FOR EPARTMENT USE ONLY" ' Application Accepted biEZ Date Area / Pit or Grout Inspection by� Date aminal Inspection by # Date I Additional Comments: ° - #/j I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - D.Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.'Hazeltcn Ave., P.O. Six 2009,�Stk., CAF95201 FEE AMOUNT DUE AMOUNT REMITT.Eb., CK# ; RECEIVED BY DATE PERMIT•'NO. INFO CASH +EH 13-24(REV.k/65) 1.J� Cr g--S p �t EH 14-26 �}!/