85-400 - Laserfiche WebLink

Home Browse Search

z. ' 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.:TNs 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. �y1 "" Job Address Q 0 City Lot Size PM 1 Owner's Name 4L,1–V_ Address f d 91K SIL __ = Phone 4O / Contractor Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ W INTENDED USE TYP.E,OF WELL 1, PROBLEMAREA } CONSTRUCTION SPECIFICATIONS ❑ Industrial 0--Open Bottom... 170 Manteca Dia. of Well Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications :.4 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout `. f ❑ Irrigation L—Approx. Depth's ❑ Eastern Surface Seal Installed byOQ Repair Work Done Type of Pump H.P. State Work Done 1 ; t -"',Well Destruction Diameter Sealing Material [top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONW(No septic system permitted if public sewer is t .• , _ available within 200 feet.) Installation will serve:. Residence_ Commerciai_ Other d ' # y Numbe'r-of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK "6 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ y Method of Disposal i �Distance to nearest: Well Foundation Property Line t . z LEACHING LINE 40 No. & Length of lines Total length/size FILTER BED ' ❑ Distance to nearest Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size f Number SUMPS CY Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. I 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 Californ 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 she employ persons subject to workman's compensa- tion laws of California." The applicant m st call for all re wired inspections. Complete drawing on reverse side. a Signed Title: Date: _ i FO DEPARTM NT USE ONLY Application Accepted Date Y Area " Pit or Grout Inspection by / Date Final Inspection by Date dd' onal Comments: Td'+ Z rk T_42&.e 01t, !A� tk 466-6781 ; ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 cant- Return all copies to: Environmental Health Permit/Services 1601'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , iy FEE Y INFO AMOUNT DUE (AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO. r + EH13-24(REV,1/6 b) C-� i EH 14-26 Lo U0 1 0 r