85-333 - 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) RIAC e( /I 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 C unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District a' Cs C C� ��o ((� /? I�. •� 7 l7 d4 2 eDL S PM Job Address '!s /NODI ` City/ Lot Size Owner's Name B�!/2/J� CA Address _G�i/ W.I. Phone '4 Contractor's Name J f'/ A License No. �' � �� Phone TYPE OF WELL/PUMP: NEW W LL ;8 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION K SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 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 V Manteca Dia. of Well Excavation 1A Dia. of Well Casing ,4 Domestic/Private AGravel Pack ❑ Tracy Type of Casing Specifications C 1,9 6- /111 ❑ Public ``��❑�Other jQ g El Delta Depth of Grout Seal Type of Grout - -' F-1Irrigation ,AApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump Sl-' t i H.P. / State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 W Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION JK REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) - Installation rve. Residence Commercial_ Other Number of living units: Number of bedrooms_ 0 Character of soil to a depth of 3 e ater table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ < Method of Disposal Distance to nearest: Well oun /40 Property Line LEACHING LINE Jhf No. & Length o c�ac� _ 4 �✓� Total lengt FILTER BED ❑ Dist o nearest: Well.A Foundation /6 Property Line O SEEPAGE PI ❑ Depth Size Number SU El Distance to nearest: Well Foundation Property Line ISPOSAL 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicants must call for all required inspections. Complete drawing on reverse side. Signed X Title: - / �'cF /' Date: �� �rr �rjv C2 CC FOR DEPARTMENT SE ONLY lie Application Accepted byzz Date Area 4-7Pit or Grout Inspection byy' Date :Z3_F_5F al Inspection by Date Additional Comments: ❑ 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 CAH RECEIVED BY DATE PERMIT`NO. +EH 1324(REV.10/83) $ ICY-%13 EH 1428 , 0 tJ� /�/ S n 5 33 Li