85-1509 - Laserfiche WebLink

Home Browse Search

�a - . s 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 Rules and Regulations of the San Joaquin Local Health District. j; yy��,, p L� /� Job Address N t�4 qo ��/� A "•k"` V J City 5+04 4 A Lot Size I-Z 1 r,L` PM8O0 Owner's Name iiAddress Q f�_ R ONO"' �� honee# lContractor G f'f spate Address I®7'JI 6MC4, 864 �Ln� PhoneL_7'+/$4) _� TYPE OF WELL/POMPNEW WELL Ll,/ WELL REPLACEMENT ❑ DESTRUCTION ElPUMP 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 SPECIFICA IONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 9Gravel Pack ❑ Tracy Type of Casing � Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal LType of Grout-54M� 11c ElIrrigation ---Approx. Depth ElEastern Surface Seal Installed by C11 "�'Y�ICTCJY Repair Work Done ❑ Type of Pump H.P. State Work Done_ ,,ttWell Destruction El Well Diameter 2- ( • Sealing Material (top 50') 1% Monitoo Depth 70 Vt Filler Material (Below 501 TYPE OF SEPT ORK: 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 ❑ No. & Length of lines Total length/size vl FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property'Line DISPOSAL PONDS ❑ 1 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 must c II for all required i pections. Complete drawing on reverse side. �'�y'D U�t. Date: '�'�'S Signed ` Title: (�lKc 1 t$ P DEP RTMENT US ONLY e Application Accept by G� Date f % Area /77 Pit or Grout Inspection ' Date �y$� Final Inspection b � G{ Date Additional Comments: � � G /�lG�' G/J tC f�Lf�rr'`,'�" /,��✓rt /d'�CC f/� 2r2"` �G .�1�7 . ❑ 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 CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.1/85) 3.vo 1213 AV (7.-/to-f5 SS-/SOS EH 14-26