85-241 - Laserfiche WebLink

Home Browse Search

( APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 andior install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welly pump and the R es and Regulations of the San Joaquin Local Health District. 1\I Job Address City z-p Lot Size 117 PM Owner's Name ALV_ r �2 Address --,e Phone Contractor's Name Aov ,. License No. Phone 7._ TYPE OF WELL/PUMP: NEW W L WELL REPLACEMEf DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR Ll OTIHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES �- r r '��'" r � _ DISPOSAL FLD. PROP. LINE z[CC� FOUNDATION AGRICULTURE WELL OTHER WELL__ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t Domestic/Private *Gravel Pack ❑ Tracy Type of Casing ea- _4 1�42 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 5-01 Type of Grout C'�ltew ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 3 _ State Work Done Q Well Destruction Well Diameters Sealing Material (top 501 C Z1W U Depth � Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is :L--,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 y7�1 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 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 employ persons subject to workman's compensa- tion laws of California." The applicant mu all f II re 're pec 'ons. Complete drawing on re�si Signed Title: Date: FOR DEPART ENT USE ONLY Application Accepted by ff c� Date f Area Pit or rout Inspection by Date '21- J Final Inspection by C at s Additional Comments: ❑ Stk 466-6781 ❑ 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 REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 1324(REV. 10183) EH 1426