85-795 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 11-'3 d- /Z ;-s cD �. 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) 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. � Job Address / �1 CI _„ City. Lot Size Z PM W Owner's Name Address `-- ,.�I-IJ �rN Phone Contractor's Name License No\ 4� 0��/ --- Phone TYPE OF WELL/PUMP: ... NEW WELL ❑ WELt RIEPLACEMENT ❑ 21 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION CULTURE WELL bTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA—CONSTRUCTION SPECIFICATIONS \ ❑ Industrial ❑ Open Bottom 13-MantecayDia. of Well Excavation Dia. of Well Casing O N .. �f 11 Domestic/Private ElGravel Pack Tracy Type of Casing_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal - Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern L---)-SuiT'aceea ni`ET96tl by Repair Work Done ❑ Type of Pump H.P. _-State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBBIOw,50')r -'r I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONX DESTRUCTION€Cl INo septic system permitted if public sewer is available within 200 feet.► Installation will serve: Residence_ Commercial_ Other Number of living'6ts: Number of bedrooms S � Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. jREATMENT PLT. El Method If Disposal .� . t Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines F- - Total length/size FILTER BED ❑ Distance to nearest: Well p d. Foundalion -b Property Line _..-_...__ w , SEEPAGE PITS ❑ Depth Size Nu ber SUMPS " ,❑ Distance to nearest: Well 16t!) Foundation A Property Line ._ .._ DISPOSAL PONDS ❑ i f I hereby certify that 1 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, j Home owner or licepsed agent's signature certifies the following: "I certify that in the performance of the work for 4vhich 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:5r,l 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 Calif The applicant m alt for all required inspections. Complete drawing on reverse si ; 7 f Signed S Title: Date: / / RW `{ FOR DEPARTMENT USE ONLY Application Accepted by 4 Date –2 Z Area r Date /fs Pit or Grout Inspection Date Final Inspection b __. Additional Comments: --- ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-638.5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE S INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + + EH 1324.SREV.101831 EH 14-28' Y