85-412 - Laserfiche WebLink

Home Browse Search

F APPLICATION FOR PERMIT R SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA A Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR•FROM DATE ISSUED d { (Complete in'Triplicate) r Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein•descnbed.•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. { Jab Address / r t City -ivrt Size PM , • .. 3 7_ Owner's Name Address. m r Phone a Contractor Address Y►e License No 6 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATIP14 �� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK PY 7i SEWER LINES DISPOSAL FLD. PROP. LINE/Qd FOUNDATION d2 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA .CONSTRUCTION SPECIFICATION i _ en Bottom �n Manteca ndustrial ❑',Op ,, pia. of Wel Excavation Dia._of_WeIlwCasin�, ❑ Domestic/Private "ravel Pack ❑ Tracy Type of Casing Specifications q E] Public CIOther E] Delta Depth of Grout Seal r `' Type of Grout C r"'P117 [� r f'1 a- ) ❑ Irrigation C 1ZApprox. De ih_ ❑_Eastern Surface Seal Installed by Repair Work Done ❑ type of Pump H.P, State'Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 ' V4� Depth Filler Material (Below 501 J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will server Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: . � . } Water table depth i _ r acNo. Compartments SEPTIC TANK ❑ Type/Mfg Ca t r� '' p .tY �k � PKG. TREATMENT PLT. EJ •- ,, , �` Method of Disposal Distance to nearest: Well Foundatiori r Property Line ; . z LEACHING LINE ❑ No. & Length of-lines Total length/size { FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS 1-1Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Li 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. 1 `Y i ` ` Home owner or licensed agent's signature certifies the following:,t 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 appl' t call for all requi nspec' ns. Co late drawirig on reverse _ Title: Date: Signed _ FORsDEPARTMENT'USEb"NLY Application Accepted by 4' Date. Area Pit or Grout Inspection by Date- Final Ihspectf6n by Dat f f. dditional Comments: # u Stk 466-6781 D 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 , FEE AMOUNT DUE AMOUNT REMITTEDCASH E RECEIVED BY 3 DATE_ PERMWNO. INFO . +EH 18-241REV.1/85l CSS C7 � 'M.:�"".': } - '}� `!} 4 Y - --� EH 14-26