85-1124 - Laserfiche WebLink

Home Browse Search

Itt IC Z. e. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT V r - 1 1601 E. HAZEL T ON AVE., STOCKTON, CA Tefiephc ne-(209) 466-6781 PERMIT EXPIRES 1.YEAR'FROM DATE ISSUED 1 in Tri a {Complete ktel P� ii '-,,, f, ,s��r}�'•.- � ..r ..� - �.ti � - =: 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 Ryles and Regulations of the Joaquin Local Health Distl+�f,57 � Q.�-�Tr ?5'r'/�(/j� " PM �9 70 Job Address r"7 �• Q .M Y ..E , { City a Lat Size --,- � Owner's Name Address �� 'r r�r� Phone Contractor • Address Q icense No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ElDESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK '4- SEWER LINES DISPOSAL_ FLD. PROP. LINE W �x FOUNDATIONAGRICULTURE WELL -BOTHER WELL PITS/SUMPS_.— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing Domestic/Private )<Gravel Pack Tracy Type of Casing Specifications ED Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grou ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done Well Destruction ❑ 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS- ❑ Depth Size Number SUMPS = M ❑ Distance to nearest: Well Foundation� '-Property Line- DISPOSAL ine DISPOSAL PONDS ❑ I hereby certify that 1 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 signatur certifies the following:"I certffy 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 C lifomia." The app' ant ust call for all re 'ed inspectio S. Complete dr i o ► everse side. _ Q Signed Title: I �i/,L Date:' s. FOR DEP 'RT ENT USE ONLY Application Accepted by Date I—A Area -1 �-Date�� Pit or Grout Inspection-by S Date �' Final nspection by Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy/ 835-6385 D ✓RG /RCS" Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE. AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO 4 + EH 13-24(REV"i/651 EH 14-26