85-1522 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in.Triplicate) _. 'z 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. xf , .. . i, i x - 9Job Address City � Lot Size PM_ Owner's Name /KRDMAddress '76 • _10V Phone 26 7-9/9110 Contractor's Name License No. F /Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION p� PUMP INSTALLATION ❑ SYSTEM,REPAIR ❑ 02MER. f❑ r""� �� f DISTANCE-TO TANK SEWER LINES,. f DISPOSAL FLD. PROP.LINE \1 FOUNDATION .--_,AGRICULTURE WELL OTHER WELL PITS/SUMPSti� INTENDED USE- TY 0,E OF'W.,ELLJ ROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial t _ ❑ Open Bottom ❑ Manteca-_____ -Dia-o#-Wall-.Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications D Public ❑ Other Er-Delta Depth of Grout Seal Type of Grout � f ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by .Repair Work Done ❑ Type of Pump H,P. State ork Donal Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below } (� TYPE OF SEPTIC WORK: NEW INSTALLA 17 ONs❑' REPAIR/AbDITION 97 aS UCTION C1 No septic system permitted if public sewer is `� }N .available within 200 feet.) Installation will serve: ResidenceA`J6�bmrnercial Number of living units: Numbertof bedrooms Character of soil to a depth of 3 feet: ` t Water table depth--3— I p P, t +� I SEPTIC TANK ❑ Type/Mfg capacity o. Compartments PKG. TREATMENT PLT. ❑ f ;'gethod of Disposal Distance to nearest: Well--i -- Foundation I,l✓� roparty Li ke LEACHING LINE 40ro No. & Length of lines Tot I length/size}- a � FILTER BED ❑ Dis nc to Weare t: 'b'del�i�"�' Foundation F '," Property Lite IS zlAtz I SEEPAGE PITS 410)' Depth Size w2 siumbe6I�� f SUMPS ❑ Distance to nearest: Well - F Faun" ,iron: � Property L ne "� DISPOSAL PONDS ElI l hereby certify that I have prepared this application and that the Work will hie.clone-in'accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.. " i Home owner or licensed agent's signature certifies the following: "I,'certify that infIt performance of the workifor which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Califorgia."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance bf the workLfor which thispermit is issued,I shall employ persons subject to workman's compensa- tion laws lifornia." The applica t mus all for all quire pe ions. Compete drawing on.'reverSe s d e. y 4y� Signed zdfdd AItle:'" _ 9JL Date: FOR DEPART•MENTp. ,USE[ONLY; d { Dat �vf Ar " Application Accepted by - ^ e rea •I or Grout Inspection by cili Date Final Inspectibn by Date !! '1.i_# 1 I-0 Additional Comments: { — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man eca 1823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health n!,tUServioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i�FEE AMOUNT DUE AMOUNT-REMITTED' AGK' RECEIVED BY DATE PERMWNO. INFO MO .-_ -_J GAP/S�H + EH 3-24£H i4-281REV.01831 "75� 7�4'� r li �� f I