REMOVAL_1985 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 Ryles and Regulations of the San Joaquin Local Health District. II J �r i_'� l/'�l j i i' F ;• City Job Address Lot Size PM Owner's Name Address s' Phone J,i; *Ci Mil: Ad License No,.,` phone ze TYPE OF WELL/P MP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ------(fq— SEWER LINES DISPOSAL FLD. PROP. INE FOUNDATION p AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ an— t�eca Dia. of Well Excavation Dia. of Wcll Casi g ❑ Domestic/Private "o Gravel Pack ❑ acy, Type of Casing Specificatl s ublic �� ether"' G ❑ Ito Depth of Grout Seal Type of GuZ n Irrigation ---Approx. Dept � ❑ E st� Surface Seal Installed by J° Repair Work Done ❑ Type of Pumpt H P. State Work Done Well Destruction ❑ Well Diameter �` Sealing Material (top 501 � Depth Filler Material (Below 50') TYPE OF SEPTIC WORK NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if putlic sewer is r iI/ •�,1�;.� cf t ` available within 200 feet.) n��allatiofi will servef.' Residence Commercial_ �ther 1141 r#i`6V( WiKg' untts�'' �!`'�imb�r of�i�drooms t L l r�;:, ✓ria (.A 17- 4 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 P NG LINE 11 No. —— Total length/size v FILTER BED ❑ Distance to nearest: Well Foundation Property Line rKlj- 37 1 S EPAGE PITS ❑ Depth Size Number —� S MPS ❑ Distance to nearest: Well F undation Property Line DI POSAL PONDS ❑ I re certify that I have prepare i application and that the work will a done in accordance with San Joaquin county ordinances state s, ard rut s and regulations of the San Jo Local Health District. Ho a owner or licensed agent's signat re certifies the foll?WM: "I certify t at in the performance of the work for which this pe it is i sued, shall n?t em loy any person in such manner as to ecome subject tb workman's com . nsation laws of California."Contractor's hiring ors b-cont actinognatu e ce ifies the following: "I certify that iR performance of thewwork for whicf1 this permit is issued, I shall employ persons subject t work an's c ens do laws of California." TJh applicant must call for all requili d inspections. Compl' �raing on r verse side 1 Sed ii r Title: r' / Date: / �. €PART ENT USE ONLY , G I Aication Accepted by Date Are Pr Grout Inspection by DateFinal Inspection by Da A • I I ❑ Stk 466-6781 ❑ Loi eco 7104 ❑ Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK P RMIT NO. INFO RECEIVED BY DATE CASH + 13-24 i /85) EH 14-26