85-1405 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT n 1601 E. HAZEL T ON AVE., STOCKTON, CA nom/ 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. Job Address � City....4 k7Pe_o>—Lot Size PM Owner's Nam L9/,7 Address ��25—y 5 u hone Contractor m;,- "l7 Address ,��C �N License No. Phone 9 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK — 1) SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l D/ Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing STV Specifications 1 Public ❑ Other ❑ Delta Depth of Grout Seald r Type of Grout r ❑ Irrigation fo��Approx. Depth Eastern S e Seal.I tailed by Ji&C I w meq] aL 14_L Repair Work Done ElType of Pump H.P. State Work Done_ O Well Destruction ❑ Well Diameter Sealing erial (top 501 Depth Filler Material (Below 501 1 n 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 G 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 ❑ I 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 ompensation laws of Calif ia.,, The cant mu call for all re d i pectio . Complete drawing on reverse side. Signed X Title: P S Date: /©? f ^ FOR DEPAR ENT USE ONLY Application Accepted by _ �_ Date- �'' J Area { Pit or Grout Inspection by Date Final Inspection by Al Date%�� Additional Comment : OLJt5rGp.� ❑ Stk 466-6781 ❑ Lodi 369 1 01anteca 823-7104 QlAracy 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'N0. S �S + EH 13-24(REV 00 EH 14.28