85-182 - 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)' 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. /-0'r_;;"720 :510--v7O5 ?tT,°- Job Address AS--rr—Coty ! � R '�`�b d�eb�' � Ci /�1�G Lot Size !�Z PM Owner's Name DO, IAfO , Address Phone t'y Contractor's,Name �.. �� FUGLcs-� License No. 6-6--5-.;2_ Phone V'? 14 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ~DESTRUCTION ❑ PUMP INSTALLATION ❑ _ �'SYSTEM REPAIR Ell ` '. i OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �T 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 ❑jOther Grout Seal Type of Grout ❑ Irrigation —L.—Approx. Depth ❑ Eastern Surface Seal Installed by a„ Repair Work Done El +H Type of Pump' P (A . State Work Done WeII-I Dest uctiori ❑ Well Diameter{ Sealing Material (top 50') v Depth Filler Material (Below 50') TYPE OF SEPTIC WORK NEW INSTALLATION REPAIR/ADDITION ❑ -DESTRUCTION ❑ {No septic system permitted if public sewer is Installation will serve: Residence I Commercial_ Other Number of living units: r Number of bedrooms Character of soil to a depth;of 3 feet: j- - -A ISD a i3 5 Water table depth SEPTIC TANK Type/.MfgP-'ckk, Capacity �&mo No. Compartments PKG. TREATMENT PLT. ❑ wq 71 "�ry ,� Method of Disposal i Distance to nearest: Well '�` Foundation Property Line LEACHING LINE1 No. &-Leof lines `T�(}Z7 _._ Total ler'dth/size FILTER BED ❑ Distance to-nearest: Well Foundation [L 'Property Line Z6/7 •SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well ti "Foundation 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."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." S The applicant must call for all quired inspections. Complete drawing on reverse side. Signed X ,�dt' /.c c1 Title: Date: F R DEPARTMENT USE ONLY Application Accepted by z L��Lr Date 16 f5 Area 40 Pit or Grout Inspection by Date Final Inspection by lam' Date -W) �� Additional Comments: } ❑ Stk 466-6781 ' ❑ Lodi 369-3621 ❑ Manteca—.823-7104—p Tracy"83�r63� V Applicant- Return all-copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE j AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. +Eat 1324{REV, 10183) To , EH 14-28 l w1U