85-719 - 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 r Jh (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. Job Address" 3 .� G T_ep 4J_Do __ _ City � Lot Size PM CU F , Owner's Name;:. ��" ~" Address s Phone t Contractor .,,4-,,Z, �JGG Address `r License No.a�,s� Phone / + TYPE OF WELL/PUMP: , NEW WELL 9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \ i- FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS - - - -- --- . - 0 15- 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 `s ❑ Public LJ Other El Delta Depth of Grout Seal Type of Grout V ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done s Well Destruction ❑ Well Diameter Sealing Material (top 50') v Depth Filler Material (Below 501 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_,,ether < Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: '_`""__ A Pen =`__...-.- --.. -- Water table depth SEPTIC TANK S� Type/Mfg CapaciNo. Compartments PKG. TREATMENT PLT. ❑ - - j Method of Disposal Distance to nearest: Well AVO Foundation 6'20 Property Line u° LEACHING LINE No. & Len th of lines f' g, !_-'__"�.�� Total length/size �o FILTER BED ❑ Distance to nearest: Well ) Foundation l0�` Property Line lgv t SEEPAGE PITS - -❑- Depth # Size Number l SUMPS ❑ Distance to nearest: Well Foundation Property Line f DISPOSAL PONOS ❑ hereby certify that I have preparedthis 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, 1 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&5 _St call for I r red ins ctis. Complete drawing on reverse side. Signed X,/ Title: Date: a tti, FOR DEPARTMENT USE ONLY Application Accepted by Date Area' .Pit o .r Grout Inspection by Date Final Inspection by 40 f:k Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERmrrNO. + EEH 13-24 H 14261REV.F/a5) "71