85-1353 - Laserfiche WebLink

Home Browse Search

p APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Rules and Regulations of the San Joaquin Local Health District.,.,,, Job Address �Y _ C' � 6 –Lot Size `' PM Owner's Name Address -4) Ilk- P Phone 3 1 2 Contractor's Name License No. 5 Phone ` 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 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ? Eastern Surf aQe Seat Installed by Repair Work Done Type of Pump H.P. ( �� _ State Work Done Well Destruction ❑ Well Diameter f Sealing Material (top 501 Depth Filler Material (Below 501 y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-C DESTRUCTION ❑ (No septic system permitted if public sewer is f available within 200 feet.! Installation will serve: Residence_ Commercial_ Other 7` Number of living units: Number of bedrooms t rn Character of soil to a depth of 3 feet: }f ' r�y. Water table depth SEPTIC TANK ❑ Type/Mfg '� yy ' Capacity No. Compartments PKG. TREATMENT PLT.❑ F '3' d Method of Disposal , Distance to nearest: Well Foundationr Property Line E ly LEACHING LINE ❑ No. & Length of{Iris""^• — Total length/size- FILTER BED ❑ Distance to nearest: Well Foundation Property Line I I SEEPAGE PITS ❑ Depth Size I t Number SUMPS ❑, Distance to nearest: Well Fobndation"""�'-; Property Line –, DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San"'Joaquin county ordinance`s state laws,-and rules and regulations of the San Joaquin Local Health District.` 4 j �. 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 emptoy persons subject to workman's compense- tioh•laws of California." The app{ican s II for all reqp Ifeinspe ons. Con/ to drawing on revere de. _ Signed f Title: 5 Date: FOR DEPARTMENT USE ONLY / Application Accepted by Date ` � Area � Pit or Grout Inspection by Y Date Final Inspection b Date y Additional Commentts: . r �' ❑ Stk 466-6781._ ❑ Lodi 'j6-36'2i ^:. ,ff Manteca 823-7104 ❑ Tracy X83&6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.'O!Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. i INFO CASH i +EH 13-24 iREV.10/93) 1 s •"i" EH 14-48 .,ySam8 f 7