85-1246 - Laserfiche WebLink

Home Browse Search

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 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. pp cation is g qwn Job Address F � a City INA S ,E? > T� � 1 Lot Size- �S �3�PM Owner's Name— r PQ 7-�—�� Address �� /�/ /�'t'>�N /�� .S' Phone Contractor l�/tom '>??r�.t i' AOUZi�� • TYPE OF WELL/PUMP: dress /Zll Lf�/L 1, ��„ NEW WELL ----�'-� icense No. Phone 3 WELL REPLACEMENT ❑ PUMP INSTALLATION DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ � LD.1 --zS� SEWER LINES DISPOSAL FS�' FOUNDATION /_GB�� - AGRICULTURE WELL PROP. LINE INTENDED USE TYPE OF WELL OTHER WELL PROBLEM _ PITS/SUMPS _ ❑ Industrial AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Man _ teca Y!bomestic/Private Dia. of Well Excavation / Z �( Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public El Other Type of Casing ��p.�� ❑ Delta Depth of Grout Seal �� Specifications G 4 /6 d ❑ Irrigation �Approx. Depth ❑ Eastern Repair Work Done ❑ Surface Seal Installed bType of Grout TYPe of Pump S�/� H.P. y Well Destruction ❑ Well Diameter /---- State Work Done_ Sealing Material (top 50') ""*► Depth TYPFiller Material (Below 50') 1� E OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if ublic Installation will serge: Residence_ p sewer is G Commercial_ available within 200 feet.) Number of living units: Other Character of soil to a depth of 3 feet: mber of bedrooms (� SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity__ No. Compartments Distance to nearest: WellMethod of Disposal 45 Foundation Property Line C LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: WellTotal length/size Foundation ---__ Property Line SEEPAGE PITS ❑ Depth Size SUMPS ❑ Distance to nearest: Number DISPOSAL PONDS ❑ Well Foundation ---_ Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: laws, and employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contractingsignature "I certify that in the performance of the work for which this permit is issued, I shall not certifies the following:"I certify that in the Performance of the work for which this permit is issued,I shall employ tion laws of California." p P Y Persons subject to workman's o pensa- The applicant us t call r M;:;ZA� rawing on revers ide. Signed Title: Date: s" FOR DEPARTMENT USE ONLY m 5 3� Application Accepted by _ Pit or Grout Inspection by fruv }— St �v Date Area p Date 94-1VFinal Inspection by— Q�` Additional Comments: Date ❑ 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 INFO AMOUNT REMITTED CK CASH RECEIVED BY DATE 13-24(REV.�ies� G PERMIT`NO. raze �� -tZLA7