85-920 - 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 ' �tt (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 CouTity Ordinance No.549 for sewage or No.,1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District 4. , Job Address :, Lot Size - ,P�, 5F0�[0 C �� ' C ty • Address Q ��` ' 1723- Owner's Name �/f� �' l I Phone�/ 9 or T44� Contractor Address ��. License No. Phone TYPE OF WELLIPUMP: NEW WELL El WELL REPLACEMENT DESTRUCTID y "PUMP INSTALLATION❑ - SYSTEM REPAIR ❑ 0TH£ ❑ DISTANCE TO NEAREST: SEPTIC TANK'. _ SEWER LINES DISPOSAL FLD. ?2 4- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r ❑ Industrial ❑ Open Bottom X Manteca Dia. of Well Excavation 4n Dia. of Well Casing XDomestic/Private Gravel Pack ❑ Tracy Type of Casing Z� Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal V, Type of rout ❑ Irrigation 1 --Approx. Depth Cl Eastern Surface Seal Installed by Repair Work DoneID !Type of Pump= H.P. State Work Done F rf ell Destruction `'�❑ Well Diameter t_y_._ Sealing Material ('top 50'1 _ 0LO C I V Vv&J-Depth Filler Material (Below 50') _6:cmu Ila Wr`l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ `Commercial--' Other , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ -Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/eine FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth } Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I'hereby—ce`rtify that I have prepared-tfiis'appiication'and that the work-will be done in accordance with-S'ari 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 followil 6_aH r'that in W performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California.''= ! The applicant ust call.for all re_ fired inspections. Colle on r arse,side. p .p Signed 4` 2W A. Title: Date: 4 a R MENTU NLY fr7 Application Accepted'.by + r- Date Area 1 J '1 "� p f Pit or Grout Inspection<'by- A� A e lj�13��final Inspection by !v Date Additional Comments: '--_ - L'?�liVE3L � ❑ Stk 466-8781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385sLil Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. ax t .,SC 95201 I - ' i 1 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO- INFO �J � '^` +EH 1324 ill 1/e 51 � �` -Ay EH EH 14-26 r