85-317 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t and/or in all the work .This cation is madle n compliance with SanoJoaqu nthe San County Ordinance No.DistrictJoaquin Local Health 549 for sewage or permit 1862 for cwell/pump and the Rules and(Regulations of he San l Joaquin Local Health District. / Lot Size PM Job Address 17 � City Phone •-- Owner's NameAddress `v L Contractor's Name �� - License No. — Phone r s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Bim' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION.. PECIFICATIONS Dia. of Well Casing , Q Industrial ❑ Open Bottom ❑ Manteca ? Dia. of Well Excavation Specifications domestic/Private ❑ Gravel Pack F-1Tracy %/J Type of Casing 1 ❑ Public Q Other El Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. De th ❑ Eastern `r,StYpace Seal Installed by A- W H.P. d } State Work,Done Repair Work Done ❑ Type of Pump ( A. Well Destruction E3 Well Diameter, I ` Sealing Material (top 50'i } 1 Depth I Filler-Material IBelow 501 # V TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDIT ON ❑ DESTRUCTION ❑ availableseptic withine200 feet.) if public sewer is } installation will serve: Residence Commercial_ OtherF + Number of living units: bedrooms Number of k z^ Water table deptpt' Character of soil to a depth of 3 feet:' r Sl Capacity 1No�Compartments SEPTIC TANK ❑ Type/Mfg; a ' 4 rMethod of Disposal PKG. TREATMENT PLT. ❑ ;,.. i Distance to nearest: Well -" Foundation Property Line '' G Total LEACHING LINE No. & Length of lines length/size _ •T . �_. ' .7 ❑' Distance to nearest: Well FoundationProperty Linee {,3 FILTER BED ly w Number SEEPAGE PITS ❑ Depth Size ; SUMPS Q Distance to nearest: Well Foundation Property Line �• DISPOSAL PONDS ❑ r, 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. Nome 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 applicantust cal r all required inspections. Complete drawing on reverse side. y2 Title: rte► - Date: Signed t., t FOR DEP TMENT USE ONLY 0 i Date d Area Application Accepted by Pit or Grout Inspection by date Final Inspection by Date Additional Comments: 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trboy 835 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE K RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AL/M-�OUNT REMITTED �{ H +EH 13-24(REV.16!931 l va 1�iJ � �—V- 6`5 3 0 EM 14-26 _ 1 t _