85-887 - Laserfiche WebLink

Home Browse Search

d APPLICATION FOR PERMIT I . SAN-JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE; TON'AVE., STOCKTON, CA Telephone (209) 466_6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Z A. . (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 Local Health District. Job Address d is F# C City S k ' Lot Siiey_—4&- AG**9 PM �i. t Owner's Name 6DD6SSy LAPOO IC16 .tom N—R-04dress - Wl.-fw Phone- '��►' Contractor U LC~d Address-4 OY S•W4TIAL-00 License No.33"19 Phone 1 rT03l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 4,CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.Tof Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ g -' Specifications r ❑ 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 p Well Destruction ❑ Well Diameter Sealing Material (top 501 G Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION C1 (No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence, Commercial Other A14(WeY�W Y Number of living units: -�- Number of bedrooms Character of soil to a depth of 3 feet: CLA Water table depth SO t SEPTIC TANK X Type/Mfg nC X0"4• Capacity "o No. Compartments PKG. TREATMENT PLT. 01 i Y Method_of.Disposal Distance to nearest: Well ! Foundation. Property Line LEACHING LINE No. & Length of lines 9 Total length/size FILTER BED ❑ Distance to nearest: WellFoundation ' -�l Property Line c� SEEPAGE PITS )e Depth 2&< _ Number 1 SUMPS ❑ Distance to nearest: Well Foundation 410�..,-_ Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepaied 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."Contractor's hiring or sub-contracting signature ' certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compe' tion laws of California." The applicant m .call for all rnsa- equiredX;X_ te drawing on reverse side. rt Signed� �� Title: — Date: ' r it OR DEPARTMENT USE ONLY w Application Accepted b r ` Date S Area �� 4 Pit o* Grout Inspection by Date Final Inspection Date*Z'01' - Additional Comments: -- ❑ Stk 466.6781' is ' ❑ Lodi `:.369-3621= ry ❑ 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 INFO AMOUNT DUE AMOUNTREMITTEDGASH RECEIVED BY f DATE PERMIT'NO. + EI241REV.i/s51 EHN IW 1426 S• a3 1