85-1333 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (20.9) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , 1 (Complete in Triplicate) I 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin ® Local Health Disttricct./ i { Job Address 2 J l� o \Sez M' Rord _ City _ZC AL.0,t� .Lot Size-9, 710 M Owner's Name Address Phone �f b1 Contractor's Name t License No. CkJ Phone l�l TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ li PUMP INSTALLATION SYSTEM REPAIR 11OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE O 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 S/ Domestic/Private +Gravel Pack{ ❑ Tracy Type of Casing - Specifications ❑ PuDlic� ❑ Other El Delta Depth of Grout Seal °� .a'-\.Type of Grob 1 F —r----�❑-krrigation :::::::::--4pprox-Depth-m-9-Easterner^—Surface-Seal-Instakied Repair Work Done It Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ftop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if Spublic sewer is available within 200 feet.k - I F�- Installation will serve: Residence_ Commercial— Other = Number of living units: Number of bedrooms tL Character of soil to a depth of 3 feet: } Water table depth SEPTIC TANK ❑ Type/Mfg [ Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method bf Disposal � 7 Distance to nearest: Well Foundation Property Lihe F I - • LEACHING LINE ❑ No. & Length of lines Total Iength/size .'� FILTER BED ❑ Distance to nearest: Well Foundation pr3p&Ry--C(ne SEEPAGE PITS ❑ Depth r Size Number r SUMPS ❑ Distance to Ihearest: Well Foundation, Property Line DISPOSAL PONDS ❑ - + 1 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."Contractors hiring or sub-contracting sigriature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of Cal'rf�a.�. } r i r The applicant m call for all required inspections. Complete drawing on averse side. �t � Signed r itle: s ti.FT Date: + FOR DEPARTMENT USE ONLY Application Accepted by r Date Area 0 I Pit or Grout Inspection by Date ✓ Final Inspection by Data Additional Comments: ❑ Stk 466-6781 �f ❑ Lodi 361}36221) ❑ Manteca 823-7104 ❑ Tracy 835-638e- Applicant 35-Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE i AMOUNT DUE � AMOgUNT�REVMITTED RECEIVED BY DATE pPERMIT-NO.CH +EH 1324/REV. �� EH 14-28 { Isk / A