85-365 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Ryles and Regulations of the San Joaquin I Local Health District./ (�� ) �j `rte .1 LV. �tJf/ ��5 'Job'Address'��_ City Lot Size PM 10 Owner's Name � Address41 Phone Contract } Address C.-a. "R 1101 '�.L+ License No.� 2O (6 Phoney ��-510E TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 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 ❑ Domestic/PTivlate ❑ Gravel Pack ❑ Tracy �;, Type of Casing Specifications I ❑ Public ❑ Other ❑ Delta a 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 r" Well Destruction ❑ Well Diameter Sealing Material (top 50') C Depth Filler Material (Below 50') v 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 I Number of living units: J_--Number if etiro s Character of soil to a depth of 3 feet: A 91an Water table depth 1,00 SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ ' . ��------�—•--Method-of'Disposal ' Distance to nearest: Well Foundation N l Property Line LEACHING LINE ❑ No. & Length of lines'-: Total length/size J• FILTER BED _ ❑ Distance to nearest: f Well Foundation I �,_ Property Line 1 5 SEEPAGE-PITS 41"' 3� 4-Depth �7 Size - — ' p ..._ eNumber' SUMPS L] Distance to nearest: Well t S0 Foundation oaf Property Line DISPOSAL PONDS 71 --- - � , "V 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 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."Contractors hirirtig 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." 'ice f ; The applicant&ust call for r wired inspections. Complete drawing on reverse side. Signed Title: - ►1 .'Z, Date: *� ' FOR D ARITMENT USE ONLY' a 7: Application Accepted'by Date ' Are CFI, 'r Grout Inspection by Dates Final Inspection by Date Additional Comments ❑ Stk 466-MlElLodi 369-3621 ElManteca 823-7104 ❑ Tracy 835-5385 ' Applicant- Return all-copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 y FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0, + EH13-24(REV,1/B 5) EH 1426 JA OCCNS