85-535 - Laserfiche WebLink

Metadata

Thumbnails

Annotations

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 gyp.p v✓� 8, cK�t/t:cT��v_ (Complete in Triplicate) f� 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 San Joaquin Local Health District.. Job Address IF lRewtkt.aut'WD6WR �,*—C)126 City TR4C_�( Lot Size t© IR A0�—cSPM Owner's Name 9JLrh 'rA--;' e-&MA%LS6� Address C�0 IT• LA&LOAt, M tK& AVd- Phone a kL'--17RV1AP,4,n 0t tU-kN3 C. 10-199 Lct3' Tti,�L eff CR k Contract Address RMe%1kAkf qS6 bcense Not13T01 L Phone -d TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N DISTANCE TO NEAREST: SEPTIC TANK '^ SEWER LINES `" DISPOSAL FLDPROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �Ipdustr181 t>�ar.�t�W(� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing e1 Q ❑ Domestic/Private Gravel Pack Trac jt�l �Q y Type of Casing IPiiC— Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of GroutME ❑ Irrigation ;�4pprox. Depth ❑ Eastern Surface Seal Installed by PLC.LAlJ Repair Work Done ❑ Type of Pump NA H.P. State Work Done Well Destruction ❑ Well Diameter a- Sealing Material (top 50') _C99M 3i-fir W (0"k) f 7 V9 Depth a,40e Filler Material (Below 501 "LDIA0V &t1Af--[V-WL*( TYPF1OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is "Ar available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Age 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 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ani 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 no employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatun 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 applican ust call for all req u ed in ctions. Complete drawing on reverse side. Signe Title:$�M�V[Ac� C„r. SSC _ Date: FOR DEPARTMENT USE ONLY [ �1 Application Accepted b Date !r�"�` Area Pit or Grout Inspection by Date Final Inspection by Date c5 Additional Comments: aw ❑ 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 CK RECEIVED BY DATE PERMIT NO. + CH 3-24 1REV,(/851 EH 1126 /