85-1578 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ' SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,h STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1: YEAR FROM DATE ISSUED' {C(Omplete 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 D City Lot Size, f'Nt ' Owner's Name Address �D9 �f� � � "r `��L Phone Contractor 6• Address License No. Phone _// TYPE OF WELL/PUMP: U NEW WELL WELL REPLACEME DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.As Q PROP."LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r �,� El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private X Gravel Pack XI Tracy Type of Casing Pg , Specifications , ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type orout ❑ Irrigation ---Approx. Depth LlEastern Surface Seal Installed by f Repair Work.Done ❑ Type of Pump H.P. State Work Done � a well Qestrtion n ❑ Well Diameter Sealing Material (top 501 � uQ Depth Filler Material (Below 501 Q TYPE OF SEPT! ORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is00 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size to nearest: Well Foundation "Property Line r FILTER BED ❑ Distance ,, SEEPAGE PITS ❑ r Depth _ Size Number ' SUMPS ❑ 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 accordancd 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:"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." The"applicant ust call for all requir inspections. Complete drawing on verse side. , a Signed Title: Date: I "n FOR DEPARTMEN fJSE ONLY � � Application Accepted by �`\(yJ Date -3/ " Area Pit or Grout Inspection by4 Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 k FEE INFO AMOUNT DUE AMOUNT REMITTED. CK R RECEIVED BY DATE . PERMIT"NO." +.EH 13-241REV.1/85) iJ� ` -�J/ O i