85-685 - Laserfiche WebLink

Home Browse Search

Ir APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 Ryles and Regulations of the San Joaquin Local Health District. 1 Q Job Address �( V� A 1AQL14 ��iT City �• Lot ! ®� PM Owner's IiXe TtWit kLd IL Address 16182 161 LM - Phone c Contract &-4sr. aS Address �_ ��License No. 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 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` Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RCMIR/ADDITION ❑ DESTRUCTION 9PINo septic system permitted if public sewer is available within 2013 feet.l Installation will serve: Residence ..,Commercial_ Other Number of living units: Numi%ef of bedrooms Character of soil to a depth of 3 feet: Water table depto SEPTIC TANK Type/Mf , Capacity No. Compartments. PKG. TREATMENT PLT. ET" s A/ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ;L7 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 not employ any person in suc manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followE'1"fi certify that in the perforrnange of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Calif The ap lican uspr all requ' _ AectonC70 e`dra�n g, rse side. Title: Date / FOR DEPART NT USE ONLY Application Accepted by Date � rea Pit or Grout Inspection by D e Final Inspection by Date A ditional Comments: �Vdvl/� tk 466-6781 ❑ Lodi 369-3621 ante 823-7104 ❑ Tracy 5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH13-241REV.1/a5) EH 14.26 v xS. S- -CZ 4—