85-625 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT � y SkN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. ` j� Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I 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 nJo qui nn Local Health District. Job Address - J �C D Subdivision Name ! Owner's Name Address 4Z4,1SIC Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. ." PROP. LINE FOUNDATION s AGRICULTURE WELL OTHER WELL PITS/SUMPS { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation 11 Y i- Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ' ❑ Public ❑ Other ❑ Delta Type of Casing �E Nrrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth ❑ hdiPttiDepth of Grout Seal ❑Geophysical Type of Grout U others Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.Pp. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 50') Y Depth Filr ler Material (Below 50') I, TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR%ADDITION 7j (No septic tank or seepage pat..,permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other i Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: �• Water tabl e'depth SEPTIC TANK Type/Mfg oeo ,L `Capacity y/,2 Q ZS) No.�Compartments� PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well 'r Foundation /d ! Property Line ' DESTRUCTION ❑ LEACHING LINE No. & Length of lines "y Total length/size "'Ver FILTER BED ❑ Distance to nearest: Well Foundation -Property Line z a� SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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. 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 rot employ any person in such manner as to become subject to workman 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 compensation laws of California." _ The applicant t call for all required inspections. Complete drawing on reverse side. l Signed X Title: nl Date: FOR TMENT USE ONLY ❑ Application Accepted by Area Stk 466-6781 Additional Comments: .1 - Q.Lodi 369-3621 Pit or Grout Inspection by Date —� � --� Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: En ironmental Xealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95202 FEE BASE AMOUNT E AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ! INFO — S S 0 EH 13-24 REV. 10182 /l I0/82 500 14-26 �/