85-1479 - Laserfiche WebLink

Home Browse Search

Vp 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 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 Joaquin Local Health District. Job Address City PM Owner's Name (2-cAddressT2.Le -73 Contractor kill- ddress � �[ /7 �/ License Qf� ;9 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION a� 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 ❑ ipdustrial El Open Bottom ❑ Manteca Dia, of Well Excavation pia. of Well Casing YDamestic/Private ❑ Gravel Pack E] Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth "---L,�astern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done f Well Destruction L Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 L7 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS LlDistance 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 reguroTr an Joaquin Local Health District. Home owner or licensed agent ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ�y person in such mann as to become iect to wor n's compensation laws of California."Contractor's hiring or sub-contracting signature certifio the following: "I certify th n the perf ce f t o for whic errriF is issued, I shall employ persons subject to workman's compensa- tion I s of California." Thea plicant must require ete dra g on rever de. Signed le: - � .per /�- ._ itDate: FOR DEPARTMENT USE ONLY �- Application Accepted by Date /Z Area Pit or Grout Inspection by DateFinal Inspection by �'� Date 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 INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT NO. + EH 13-24 IREV.7/a 51 EH 1426 �� ,�