85-353 - Laserfiche WebLink

Home Browse Search

f , h APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 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. n A y� Job Address I D T1 7 P L Dm/y Ci Lot Size'-5- Kcr .-, PM Owner's Name - 1Al {'�_ Address sRiaF-2 Phone Contractor's Name License No. -,3 S-/'1 / ),- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 'DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of'Grout Seal Type of Grout ❑ Irrigation # --Approx. Depth ❑ Eastern Surface Seal Installed by 'tea Repair Work Done ❑ Type of Pump H.P. f State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resi ence f��Commercial_ ther Number of living units: � Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E---type/Mfg (� D AJ C rGtE Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well - Foundation Property Line LEACHING LINE W-14o. & Length of lines - � ��,,hhT.otal length/size e FILTER BED ❑ Distance to nearest: Well Foundation Property 1 Property Line Ll Oto— SEEPAGE PITS ❑ Depth Size Number SUMPS stance to nearest: Well Foundation LJ 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, 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." Contractors hiring or sub-contracting signature cern'es the following:" ify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion la California." The Iicant II for all uir ins c ion C late drawing 2�;��p Signed Title: Date: 4 FOR DEPARTMENT USE ONLY Application Accepted by �U'LL.t.� .�.--L Date '��` S� rea ` - — 7 Pit or Grout Inspection by Data Final Inspecdo y � Date Additional Comments: _ �- tStk.-466-6781 -❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy M5-6385-,.:.,.— �. plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO C CASH /1 + EH 13-24(REV.10183) J �q,7 0 y-'y n. SS 35-3 EH 14-28