85-573 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED (Complete in Triplicate) f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workhereindescribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Q`:� Job Address ! CtY Lot Size 'Lit PM Owner's AmC C l l Address - TWA. Phone Contractor s Address I ""�--- ► nLNo. l� TYPE OF NEW WELL ❑ Phone. WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK �y OTHER ❑ - SEWER LINES DISPOSAL FLU. PROP. LINE ! r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED U C3SE :TYPE OF WELL ;.PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial t El Open Bottom_ ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack Dia.-of Well Casing Tracy Type of Casing ❑ Public Specifications I ❑ Other tc.. ❑'Delta Depth of Grout Seal ! ❑ Irrigation IN = Approx. Depth ❑ Eastern Type of Grout {.a.-�.__ , Surface Seal Installed by f Repair Work Done ❑ 7ype of Pump - H.P. State Work Done Well Destruction-- ` ❑: Well Diamefer r Sealing Material (top 50') " j ! Depth i Filler Material {Below 501 ?TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ ;No septic system permitted if public sewer is i t Installation,will serve:+ Residerice'� available within 200 feet.) Commercial Other p� 00 Number of living units: �° Number of be roo i Character of soil to a depth-of 3"feel: SEPTIC TANK ' Water table depth � t11 Type/Mfg Capacity��-i�� 1, PKlG-TREATMENT'. - { No. Compartments r Method of Disposal Distarice`to`nearest: Well Foundation I F i -`" `X _ , ,,f Property Line LEACHING LINE I No. & Length of lines 3 _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundations Property Line IS EEPAG E PITS Depth Size 3 ' A Number SUMPS ❑ Distance to nearest: Well Foundation i DISPOSAL PONDS ❑ .— Property Line/ �� 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 Femploy any person in such manner as to become subject to workman's eompepsation 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 tion laws of California." p p y persons subject to workman's compensa- iThe applicant c for all require i ns. Complete drawing on reverse si igned} II Title: Date: 15 1fSFO DEPARTMENT USE ONLY �' A plication Accepted byAA C4 Date Area i P to Final r Grout inspection by 10-1 S�S � p t r mal Inspection by--.tom � Date V1 -$ Additional Comments: Lo`�O A�IYI. `3V P.M- ❑ 5tk 466 6781 ❑ Lodi 3 9.3621 ❑ Manteca 823-7104 L2 Tracy 835-6385 Applicant- Return all-copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009„Stk., CA 93201 i FEE/ AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE, PERMIT NO. + EN 1&24 IfiEV.1/8!5) ` EH 1426 c, . f3 fps 'CA'Ss-73 '