85-970 - Laserfiche WebLink

Home Browse Search

Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6* PERMIT EXPIRES 1 YEAR FROM DATE ISSUED"' f ` (Complete"in Triplicate) _f f 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 Ryles and Regulations of the San Joaquin j Local Health District. a. ,« t�� 1;3 11.s-,;' s, s, , Job Address {�21JC1,g1:' '. ,; ) . _ 'City' t � Lot Size D!Ch �_ PM e 10 Owner's Name -� �� =��$d�/ �... Address � G r1�1 '�= Phone - ' Can#Tactor ` �" -*- _ `,.. �5S Address I-1 License No. Phone I TYPE OF WELL/PUMP: ..n NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-El OTHER ❑ I' DISTANCE70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I � - FOUNDATION AGRICULTURE WELL OTHER WELL{ PITS/SUMPS S INTENDED USE £?TYPE-t7FWEEL —P-ROBLEM AREA._,,,;.CONSTRUCTION-SPECIFICATIONS _ EIIndustrial ` ❑ Open Boftom r a Manteca .k Dia.'of"Weli'Excavation Dia. of Well Casing F? Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta bepth of Grout Seal Type of Grout ❑ Irrigation L�__4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. k f State Work Done CD Well Destruction ❑ Well Diameter Sealing Material {top 504----; i Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.l Installation will serve: Residence-ve/Commerciai— Other /f Number of living units: Number of bedrooms_ r f Character of soil to a depth of 3 feet: - Water table depth ~" SEPTIC TANK ❑ Type/MfgCapacity -j5..A No. Compartments PKG. TREATMENT PLT. ❑ Method of Diosal Distance to nearest: . .Well h� Foundation Property Line 6.___ LEACHING LINE ❑ No. & Length of lines & Total length/size FILTER BED ❑ Distance to nearest: Well 0)C) 4- Foundation Property Line i SEEPAGE PITS ❑ Depth f Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 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 erriploy persons subject to workman's compensa- tion laws of California." The applicant must call for all req ed�ijnsspections. Complete drawing.on reverse sides.. Signed Title: T Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by r v Date Final Inspection by ate 3 'Additional Comments: ❑ Stk 4664781 ❑ 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 INFO AMOUNT.DUE AMOUNT REMITTED CK 1i-CASH RECEIVED BY DATE PERMIT'No. +EH 13-24(AEV.t/as) EH 1426 .—