85-1537 - Laserfiche WebLink

Home Browse Search

APICATION FOR-PERMIT r ' � "" PL SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED T # ,60," (Complete in Triplicate) ' Application is hereby made to the San Joaquin Local Health District far 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. 18¢2 for well/pump a the Rules and Regulations of the San Joaquin,: t Local Health District. R Job Address • 1' ' ' City Lot Size Z 4-'21 CA� PM _ / I L Owner's Name�� tl� ddress q vs- A '�j� J � s• �� C� , Phon i 5 ' c3 Contractor's Name b 1' L"S "License Na. 3,L Phone 7Y f-Zy TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ -. DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK A2_4:- SEWER LINES `�C� DISPOSAL FLD. PROP. LINE FOUNDATION a-;-AGRICU1,-T1JRE WELL' OTHER WELL - PI7S"/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONST ❑ industrial pen Bottom ❑ Manteca Dia. of Well Excavation ,. (t Dia. of Well Casing 1 4 5050mestic/Private ❑ Gravel Pack L7 Trac T t Y � ype of Casing_�_r�� Specifications _ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �I'Frigation --Approx. Depth El Eastern Surface Seal Installed by y` Repair Work Done ❑ Type of Pump L_SL� H.P. `Z. State Work Done Well Destruction ❑ Well Diameter f Sealing Material (top 501) - f ' - Depth Riler Material (Below 50') / TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ •DESTRUCTION'❑ (No septic system permitted if public sewer is Installation will serve: Residence_ F Commercial Other available within 200 feet.) Number of living units: Numbei of bedrooms Character"of soil to a depth of 3 feet: j IWater table depth SEPTIC TANK ❑ Type/Mfg 4 Capacity No. Compartments 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 ,i SEEPAGE PITS ❑ Depth Size Number -�+�:;;.SUMPS*= ^vim. - ..tODastance_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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X CEJ , „ Title: Date: FOR DEPARTMENT USE ONLY Application b Accepted 7 p y Date ,e 0�— Area • Pit or Grout Inspection by ate Final Inspection by Date! �_Z2, Additional Comments: ' ID Stk 466-6781 ❑ Lodi 369-3621 € ❑ Manteca 823-7104 E3 Tracy 835-6M Applicant- Return allcopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2809, Stk., CA 55201 i FEE AMOUNT DUE AMOUNT REMITTED INFO" CASH RECEIVED BY DATE PERMIT`NO." + EH 13-20 tAev,70/831 rs rr, EH 1a2e ,