85-1473 - Laserfiche WebLink

Home Browse Search

` APPLICATION FOR PERMIT SAN JOAQUIN: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 Son Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is machin compliance m1h 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. L Job Address jy� l.J , ► N/T4e '� c� *,e City / Lot Size PM .44'eo/2 J2aC/ 7Jk© Owner's Name ° f311 � �,f Address ll 1 � F0 Of Phone —�; Z Contractor's N4me4!! ;<Z 9:WLicense No. 23�. Phone _4:Q7 TYPE OF WELL/PUMP:' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLO. 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 D Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work.Done ❑ Type of Pump w H.P. State Work Done h Well Destruction Well Diameter �T Sealing Material(top 50% Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑, DESTRUCTIONo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ 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 l 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 employ persons subject to workman's compensa- tion laws of California." The applicant qpq call for uired inspections. Complete drawing on reverse side. Signed X� Title:—,:!6Qj. at.: /.4AyArr Air FOR DEPARTFffNT USE ONLY Application Accepted by Date J7 A' Ph or Grout Inspection by Dto Final Inspection by Date "4 Additional Comments: ❑ Stk 4664MI ❑ Lodi 369-3821 ❑ Manteca 823-7104 ❑Tracy `8354385 Applicant; Return all copi.s to: EnvironmentalHealth Permit/Services 1601 E.Hazekon Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AM TINT REMITTED CK RECEIVED BY DATE PERMtT"NO. INFO CASH Q�. +.EH 1324 IREv.10/99 /�V J o J' 1 73 EH 1426